Episode 55:
A Culture of Preparedness
Michael Dowling, President and CEO, Northwell Health
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In this episode of Fireside Chat, we sit down with Michael Dowling, President and CEO, Northwell Health to talk about his role in leading through the COVID crisis in the epicenter of the pandemic in New York City. We also covered a list of the key topics for health system leaders, including why scale matters, and how Michael thinks about growing government payments to health systems.

Michael Dowling is one of health care’s most influential voices, taking a stand on societal issues such as gun violence and immigration that many health system CEOs shy away from. As president and CEO of Northwell Health, he leads a clinical, academic and research enterprise with a workforce of more than 72,000 and annual revenue of $13.5 billion. Northwell is the largest health care provider and private employer in New York State, caring for more than two million people annually through a vast network of nearly 800 outpatient facilities, including 220 primary care practices, 52 urgent care centers, home care, rehabilitation and end-of-life programs, and 23 hospitals. Read more

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Michael Dowling 0:03
If we call ourselves a health system, we can’t only be at the downstream part of the business, which means taking care of people after they get sick. We’ve got to be equally good at preventing people from getting sick. And that’s an area that we’re working on. We’re not there at all yet. But it is the long term goal. That if we believe that we have a healthcare system, we’ve got to be in all aspects of healthcare delivery, from prevention to treatment.

Gary Bisbee 0:29
That was Michael Dowling President and CEO Northwell Health sharing his view on the importance of Northwell providing services along the entire healthcare continuum. I’m Gary Bisbee and this is Fireside Chat. Northwell Health is a top 10 nonprofit health system with $12 billion in annual revenue. Michael was born in Ireland and his professional background prior to Northwell included being chief of staff to New York Governor Mario Cuomo and time is a health insurance executive. Michael has written a book published in August 2020, Leading Through a Pandemic, which outlines lessons learned and the stories underlying them. We discuss the key stories, including how to solve the COVID supply chain disaster. Michael spoke about his emphasis on Northwell’s culture of preparedness and the importance of communication during a crisis with its one inherent danger. Let’s listen.

Michael Dowling 1:19
You cannot over-communicate. And as somebody once said, “The danger of communication is thinking that you have actually done it successfully.” So you have to do it over and over and over again and the message has to be one of optimism, have to be upbeat, proactive, and have to be reality-based, but also focused on that we will win this. There is no defeat here.

Gary Bisbee 1:44
Michael covered a list of the key topics for health system leaders, including why scale matters and how he thinks about growing government payments to health systems. He proposed that the US lead a global pandemic response initiative to prepare for the next pandemic and what role health system leaders can play. To wrap up, Michael detailed the most important characteristics of a successful leader in a crisis.

Michael Dowling 2:06
Positive attitude; balancing reality with positiveness; taking responsibility; telling the truth – don’t sugarcoat it – but keep the morale high; and communicate, communicate, communicate; be visible.

Gary Bisbee 2:25
I’m delighted to welcome Michael Dowling to the microphone. Well, good morning, Michael and welcome.

Michael Dowling 2:35
Good morning, Gary, delighted to be here talking to you. It’s a pleasure and I thank you for the invitation.

Gary Bisbee 2:40
Absolutely. We’re pleased to have you at this microphone. Let’s start by learning about your background, ask you to describe Northwell Health, and then turn to the COVID crisis. Is there anything you haven’t done, given the fact that you’ve been a chief of staff for the governor of New York State, you’ve been an academician, you’ve been a senior executive of a large health insurance company, and now you lead one of the largest 10 not-for-profit companies in the country.

Michael Dowling 3:07
Well, it’s been an interesting background. I’ve been very fortunate, quite honestly. I came to the US when I was young. And again, my history proves what a great place the US is, because if it wasn’t for the United States and the opportunities that I have here, none of the things I’ve done would have been possible. I came here, I was almost 18. And I came here by myself. I grew up in pretty extreme poverty in Ireland and I was the oldest of a family and the family was in pretty bad shape. And I actually had to leave home, I left home when I was 16 to go to England to work in steel factories, south of London, and I did it for the purpose of trying to help out at home. And I’ve always dreamed of going to college. My mother was a wonderful lady who loved learning and education, and although she had very little education herself. And when I came back from England working, I had done well enough in high school that I was eligible to go to college but I had no money, especially after the first year. First-year was paid for by the money I made in England. I came to the US and I ended up working on the docks for years and working in construction. I worked as a plumber. I cleaned out bars. I did what most immigrants do. You do what you have to do to get ahead. I ended up going to Fordham University for my master’s degree and then on to Columbia for my doctorate, which I did everything except turn in my dissertation because while I was teaching at Fordham University because after going there I was asked to go on as a faculty member and I became a full-time professor at Fordham. And while I was there, I was asked to see if I wanted to join the administration of Mario Cuomo, the governor at the time who had just gotten elected and I said yes. But when a door opens, you never know what’s going to happen. You just walkthrough. And when I got to the governor’s office, I continued to get promoted and became very close to the Governor, became his top adviser on healthcare and human services. And as you, as you recounted, I ended up spending 12 years there. And going into the insurance business after that, and then was recruited to come to North Shore University Hospital on Long Island, and valued to build a health system. And so it’s been an interesting journey. I’ve been very fortunate, very lucky. And got to be a little bit resilient and a bit adaptable, and don’t look at things as being as obstacles but look at things as opportunities. And that’s the way I’ve always looked at it. And so I can say, I’ve been pretty fortunate.

Gary Bisbee 5:39
Well, lucky and good go together, typically. So well done, Michael. Given the importance of government to healthcare in the US, what lessons did you learn in government that have made you a better health system CEO?

Michael Dowling 5:52
Well, government is a wonderful training ground and I would urge any young person if they have an opportunity to work in government, they should because you get to see the world from another different perspective. And government gets criticized a lot, but there’s an awful lot of good people in government. It was different when I was there, it wasn’t as nasty. It wasn’t as partisan. The political parties argued, but they weren’t in combat with each other like they are today. So my timing was helpful, but the current circumstances will of course, change. But being in government teaches you about the good and the bad and the underbelly of society. You see a lot of things you don’t see when you’re on the outside. You realize that government, a key important role is to provide a safety net for people at the same time making sure that it doesn’t diminish the incentive to work. And it’s a tricky balance, which I always tried to maintain. I believe strongly that, let me put it the other way, I’m not somebody that believes completely in this entitlement mentality that you’re automatically entitled to something. You’re entitled to have the opportunity to work to get someplace. And so government for me on Governor Mario Cuomo was a wonderfully exhilarating exercise and experience. But it does teach you about politics, about the importance of politics, and about the key role that government should play, and also teaches you about the roles that government shouldn’t play. And of course you can have arguments about this. But for me, it was very, very instructive.

Gary Bisbee 7:20
Speaking about partisanship, do you see a point in the future that we will go back to the point where it’s not so partisan as it is now?

Michael Dowling 7:28
It’s my dream. During COVID, irrespective of your political persuasion, irrespective of your disagreements, whether you’re Republican or Democrat, conservative or liberal, everybody unified, here in New York and our experience. Everybody unified to fight a common enemy like COVID. Your politics didn’t matter. COVID didn’t care about your politics. And I would hope that if we are to preserve the wonderful democracy we’ve got and strengthen it, we’ve got to work as one and the role of leadership is to unify, to take accountability, unify, bring people together, not separate, and not demean, and not pass the buck. That in my view is not leadership. And hopefully over time, we will have the kind of leadership that brings people together because United States is a wonderful place. Remember, think of the name – United States. It doesn’t say this United States, it says United States. If you believe in the United part of it, you’ve got to unify. And I believe that good people at the end of the day will win. And I believe hopefully that we will come back to unify around common purpose so that we can be the leader in the world that we once were.

Gary Bisbee 8:38
Well said, Michael. How did your time at Empire Blue Cross Blue Shield contribute to your success as the Northwell CEO, do you think?

Michael Dowling 8:46
Well, I spent a relatively short time at Empire Blue Cross Blue Shield. It gave me a perspective on the insurance side of the business. Despite the fact that it’s a good company and there are great people working, I didn’t enjoy it that much because I like to be on the side of the business that actually does the real work. Insurance companies tend to be middlemen. I like to be on the front lines where the real work goes on. So my stay at Empire Blue Cross gave me a good insight into the insurance side of the business, which of course is very helpful today. But I knew I was not going to stay there too long. Unfortunately, I got recruited by North Shore University Hospital and that was a very fortunate move for me to make. And I’m still very, very thankful for the people who reached out and asked me to come.

Gary Bisbee 9:32
Well, when you joined Northwell in 1995, as the VP and Chief Operating Officer, did you ever think you’d be the CEO of one of the largest health systems in the United States?

Michael Dowling 9:42
You always have a dream. I’ve always believed that whatever rung on the ladder you’re at, you always try to get higher up the ladder. And you do it the right way, you earn it so I’ve always been one that even when I played sports, I wanted to be captain. When I was back in Ireland I played sports at a high level. So you always climb the ladder if, and be competitive and have a goal, raise the bar. But I came to North Shore University Hospital, we only had a couple of hospitals. They were beginning to talk about creating a health system. I, when I was in government, had written about the need to create health systems and there was no such thing in New York. North Shore hospital was the first to begin the creation of a system. And I was there pretty much close to the beginning. Did I believe we would get to where we are today? Yeah, when I would sit back and envision the future, I’d thought about it, but how to do it, I wasn’t so sure of at the time. But you start to build and you grow and it takes a life of its own after a little while. And if you’re putting in the right people, hire the right people, create the right culture, build a system of unity and purpose, then anything is possible.

Gary Bisbee 10:51
Let’s turn to Northwell Health which is a very large company in addition to being a top 10 nonprofit health system. To provide reference, Northwell is about the same size as a company that we’re all familiar with Kellogg. Will you please describe Northwell for us, Michael?

Michael Dowling 11:09
We are the largest health system in New York State. We are also the largest employer, private employer in New York State with about 73,000 employees. But we are a full-service organization. We have the hospital side of our business, we’ve got 23 hospitals and that’s what a lot of people focus on. But about over 50% of my business today is non-hospital, non-acute. We have 800 ambulatory outpatient locations. We have a major post-acute service line. We have nursing homes. We have huge home care. We’ve got major geriatric programs focused on the aging. We’re one of the largest academic teaching places in the United States. I mean, people don’t fully realize this. We have 1950 residents and fellows. We have a very unique medical school. We have a very unique nursing school. So we’re very, very innovative on the academic front, one of the largest. And then we have a huge research entity called the Feinstein, which is renowned for things like bioelectronic medicine and movement disorder research, oncologic research and such. So we are a full service organization. I often like to describe us as, we are the largest primary care provider in the region; we are the largest ambulatory care provider in the region; we are the largest post acute care provider in the region, because I like to get away from the idea of people thinking, “Oh, all you are are just hospitals.” Now hospitals are important, they are a key part of the organization, but hospitals are only one link in the chain of the continuum of care and we have the full continuum, everything from primary care to end-of-life, plus we have something that was enormously helpful during COVID. We have our own transport network. I have about 100 ambulances on the road and I have my own air transport. So I’m full service. And we’re very community-focused. We like to improve access out into the community. We don’t believe in the hub and spoke, for example, where all of the services should be coming to one major central hub. We like to diversify and deliver services out into the community closer to where people live as possible. And it’s a work in progress, Gary, I mean, you’ll never get this fully right. You’re always annoyed with what’s not right. And as a leader, you should be. You’re always pushing to raise the bar to do things differently, to be more creative, to be more consumer-focused, and to be, and let me say one last point here. My goal is to be as good at the healthcare promotion and prevention as we are in healthcare treatment. And that gets into the social determinants of health issue, the wellness issues. If we call ourselves a health system, we can’t only be at the downstream part of the business, which means taking care of people after they get sick. We’ve got to be equally good at preventing people from getting sick. And that’s an area that we’re working on. We’re not there at all yet. But it is the long term goal, that if we believe that we have a healthcare system, we’ve got to be in all aspects of healthcare delivery, from prevention to treatment.

Gary Bisbee 14:22
We’ll cover the continuity of care a bit later, but where does scale matter? You’ve described impressive scale by Northwell. Where does scale matter, Michael?

Michael Dowling 14:31
Scale matters if you do it the right way and we are very integrated as a system, we’re completely integrated, we all work as one. So scale matters because you have the opportunity to innovate. You can do demonstrations in different parts of the organization. You can exist by having all components of the delivery system. It’s like a jigsaw puzzle. You can put it all together to provide the holistic care to populations and to patients. It allows you to develop economic strength so that you can deal with the insurance companies which have been getting very, very large and consolidating. And when you have scale, you’re a counterweight to the insurance companies in your ability to be able to get the appropriate amount of reimbursement to do the part of innovation delivery it if you want to do. And scale was huge for us during the COVID crisis. Absolutely huge. The idea of systemness during the COVID crisis was one of the keys to our success in dealing with it.

Gary Bisbee 15:31
What about the government revenue? Now most of our health systems, more than half of the revenue comes from governments. That’s likely to continue to grow. How will that affect Northwell in the future?

Michael Dowling 15:41
Well, long term I think that is a cause for some worry. We are about 64% or 65% government care. That means Medicare, Medicaid, and we’ve got about 30%, roughly a little bit more on commercial. And you have to keep that kind of a mix because remember, we’re in New York, we’re in a high priced area, we’re in the union environment, which is more costly. And if you are completely dependent upon government, you are in some financial distress, especially if your prime, predominant payer is government Medicaid. You are in real financial difficulty. This is what worries me when people talk about single-payer. And of course, there are many definitions of that. But if single-payer means that government is a full revenue source, you are going to be in financial difficulty. And that worries me long term and this is why we have to be very, very careful to maintain the public-private balance in healthcare. And I know intellectually, some people say, well, single-payer is simple. It’s easy. It’s kind of straightforward. There’s a simplicity to it. But while there may be a simplicity to it, there is real, real danger for the delivery of good care long term.

Gary Bisbee 16:56
Let’s use that as a segue into Northwell’s response to COVID and as you point out, New York was the US epicenter of the COVID surge. You’ve written a book, hot off the press entitled Leading Through a Pandemic that outlines lessons learned and stories underlying them. Why did you write this book, Michael?

Michael Dowling 17:15
Well, we were at the epicenter of the crisis, given the location of our facilities. We actually saw the book in size about 50,000, but the book went to print some time back. We have seen over 76,000 COVID patients and none of us have gone through this kind of an experience before. And right after the crisis began with us in mid-March, I began thinking and other people had mentioned it to me, that it would be good to actually document what actually we were going through. What did we have to do on an ongoing basis to respond. And what I would do is I would write on the weekend, and jot down all of the things that we went through during that week. And it eventually evolved into a book. I thought it would be instructive to other health systems. So that as you go through any kind of a crisis, there are issues that come up that you have to pay attention to, and I thought by documenting it, it could become a guideline for others. And I also thought it would be helpful to the general public. And that’s why it’s, I think it’s a readable book for the general public so that they could actually fully understand what went on. And lastly, I wanted to write about the unbelievable dedication of healthcare employees. The courage, the compassion, the dedication that I observed on an ongoing basis on the frontlines was absolutely extraordinary and humbling. And it needed to be told. I didn’t start out wanting to do the book. I started out just documenting what we were going through and it evolved into the book. And by doing it during the crisis, it was fresh. It wasn’t something that you could come at three months after the crisis and you’re trying to recount to remember what happened. We were doing it in real-time, which I think gave it a little bit more sincerity. So that was the reason. It was my weekend task. And I worked with obviously another very good person, Charles Kenney, on the book who was terrific in helping pull it all together.

Gary Bisbee 19:15
Michael, I think you should take the book back to Columbia and submit that as your dissertation.

Michael Dowling 19:21
I had my dissertation. I did advocate for the doctorate except I was known as ABD, all but dissertation. My dissertation was accepted. I went through the oral exams. Then it just sat in the trunk of my car because the governor called, at that time the Governor Cuomo was on ministration call and said, “Do you want to join the administration?” I said, “Okay. So I’ll finish the dissertation next week. Well, next week, I never did it.”

Gary Bisbee 19:45
It happens to many. You describe in the book a culture of preparedness. When did you first think about a culture of preparedness and how did Northwell develop it?

Michael Dowling 19:55
It started way, way back, over 20 years ago. Because of our location, and I coming from overseas and all, being very familiar with the troubles in Northern Ireland and in Europe, etc, I probably had a little bit of a different perspective. And our location, we’re right next to Kennedy Airport, we’re right next to LaGuardia Airport, we’re in the Manhattan, we’re in the city of New York. I’m thinking if a crisis ever occurs in this area, are we prepared? So our first meeting, our first event that I recount at the beginning of the book, was we held a meeting on weapons of mass destruction more than a year before 9/11. And we sat around thinking what would happen if there is a crisis and during that conference was when we had people from the FBI tell us about Osama bin Laden. And at the time, of course, everybody said, “Well, this is nuts. This kind of thing would never happen.” But we started to think about what happens if it occurred. You know, you’ve got to plan for what you may think never happens, but you’ve got to plan for it. So we started to put together an infrastructure about how we will organize to deal with a crisis. We have very good people here that know this business. And of course, we had 9/11. And then we had SARS and H1N1 and we’ve hurricanes, and we’ve used the structure and the emergency management information system structure all during the last 15 years. So for COVID, we held our first meeting in January to plan for what we thought would be a COVID crisis in the region. This is before we had any cases. But we were observing what happened in Wuhan and what was happening in Italy and we were talking to people in those countries. So we figured, well if we activate the structure that we put in place here for years and see if we can make it adaptable to the COVID issue and, of course, it adapted very, very well.

Gary Bisbee 21:43
Well, how are you thinking about a surge in the fall or even next year?

Michael Dowling 21:48
We assume that we’re going to have a big surge in the fall and at the beginning of the year, potentially. We’re hoping it doesn’t happen. We’re praying that it doesn’t happen. But we have to plan as if it is going to happen. So we have put extraordinary plans in place. Plans around creating the bed capacity, the staffing issue, which is always the most complicated, what do we do about PPE, how to develop alternative sites as to where to put beds. So we have unbelievable detailed plans that are so detailed, in fact, right now, that we have planned for, let’s assume in November, let’s assume we have 5000 COVID patients again, which again, as I said, I hope we don’t, but let’s assume we do. But what happens if we have that number of cases and at the same time, we have a hurricane? How do we deal with it? So we have table topped all of these exercises. And our team is pretty well prepared. So I can say with some confidence that whatever hits us here, Northwell is ready. And we will adapt and be versatile enough to take care of it irrespective of how difficult it might be.

Gary Bisbee 22:55
You make the point in the book that information is healthy; fear is not. And given the widespread uncertainty and lack of information about COVID, what was your strategy for communicating with the community, Michael?

Michael Dowling 23:07
Continuous communication. And you’ve got a number of different communities here. You’ve got the public, which we communicated with continuously in every medium we could find. And basically, the message was, we’ve got this. It’s difficult. There’s gonna be bad things happening, but we’ve got this. At the end of the day, we are going to win this battle. This is not going to defeat us. We are not the group that will be defeated here. The second large group, which was unbelievably important that I spend extraordinary amount of my time on this and that was the staff. The staff on the ground, the troops on the front lines are the people who make things work. So we communicated verbally, in written form, websites. It was continuous, daily communications. And I and my leadership team, we were on the frontlines almost every day. I walked every ICU in every one of our facilities during the height of the crisis, because I believe that it was important to be out there with the staff to let them know that we know that their safety and security and morale was top priority for us. They needed to see us out there. Leadership doesn’t hide in a crisis. Leadership makes themselves very visible in a crisis. And by being out there, by the way it also helped in putting the book together because I could observe exactly what was going on each and every day and this is how I saw the unbelievable, compassionate courage by employees. And we also, of course, have to focus in on the employee’s mental well being, psychological well being, and physical well being, which means that they wanted to know that we had enough supplies of PPE that they would never run out and we were able to ensure them that that is the case. So the communication was consistent. And the other group I had to deal with because obviously, I communicated pretty regularly with my board, most of it by zoom, of course on the weekends, and then we had the politicians and government we were communicating with. And as you know, Gary, I was working very, very closely with Governor Andrew Cuomo, whom I believe did an absolutely spectacular job here. But I was in constant communication with him and helped him coordinate a lot of stuff in the New York area. You cannot over communicate. And as somebody once said, “The danger of communication is thinking that you have actually done it successfully.” So you have to do it over and over and over again. And the message has to be one of optimism, has to be upbeat, proactive, and has to be reality based, but also focused on that we will win this. There is no defeat here.

Gary Bisbee 25:47
Just to follow up on that, you devoted a chapter in the book to clinical decision making. Would you describe the role that clinical decision making played in the response to the crisis?

Michael Dowling 25:58
Well, I would say that that was one of the key areas. We put together a very sophisticated and high end clinical advisory group that met daily, multiple times a day. Because at the beginning, we did not know a lot, about the disease. And the clinical protocols, the guidelines have to continually evolve. And the staff on the frontlines, whether they would be ICU nurses or the physicians had to be guided continuously by this clinical advisory group that came up with the continuous new standards and guidelines. And this was done system-wide. So if we found out for example, which we did, that people got blood clots, then the guideline had to go out about, “What do you do about that? How do you perfect it? What are the treatment protocols that should be put in place to deal with that?” We found out for example, that the COVID not only affected the lungs, but it affected the liver and the heart. And so, new guidelines had to go out. Our critical care staff had to constantly be in touch to make sure that we were up to date with the most current information. And then you had the whole issue about treatment trials. And new medications. How do you dispense of the medications? What medications worked with other medications? What kind of treatment trials should be doing? So we would not have been able to deal with it without a very sophisticated clinical advisory group that met all the time and was providing the guidelines for how the people on the ground should operate. Absolutely key. And that was one of the predominant lessons that is outlined in the book.

Gary Bisbee 27:35
So you mentioned supply chain earlier, Michael. How do we develop a more reliable and resilient supply chain as a country?

Michael Dowling 27:43
Well, I think this day the challenge we have now nationally is to take the lessons of this issue and so that we do things to prepare for another one in the future because you and I know, Gary, there will be another one. We were unbelievably ill-equipped. We were almost totally dependent upon, the supplies that you need to battle in this war, we were dependent upon foreign countries like China and others. That has to be done domestically going forward. We cannot be dependent. If you’re in a war, you can’t be dependent upon other countries to supply you with the supplies you need to fight the war. We should do it domestically. We need a lot more investment NIH, in NIH. We need to strengthen the CDC. We need to make sure the inventory in the stockpiles, both federal and the state stockpiles, fully equipped and that the inventory is current. We got caught with getting stuff from the federal stockpile, like vents that didn’t have any hoses attached to them. It is recounted in the book and the poor people obviously emphasized this. We had to go to Home Depot to get garden hoses to make hoses for the vents that came out of the stockpile. You should never be in that situation. I mean, we’ve known that there was going to be a pandemic coming for decades. And hopefully this lesson requires us to see this is a national problem. This is not just a state problem. We need national leadership that says we as a country should be prepared going forward. But what the last thing I would say is, I think that the leadership of the United States should be working with the leadership of China and the European Union and England to be putting together a global surveillance system on these kinds of events, and put together an international global response system. This is a global issue. It’s not just a national issue. We can’t separate ourselves from the rest of the world and hope that we can fight these things that come from the global source. This is an opportunity for the United States to take global leadership and we didn’t have good national leadership on this issue. I don’t want to get too political here, but it just didn’t happen. But we need national leadership and we need global leadership. And the United States is the one place that can stand up and say, “We lead.” If we don’t do it, others won’t. Others can’t. We can do it. That’s the challenge for the United States going forward now.

Gary Bisbee 30:04
It is a challenge. Michael. What can you and your peer CEOs, which are very influential nationally, what can you do to try to move us down the right path here?

Michael Dowling 30:15
I think that going forward, I would like to see, whether it’s by zoom or in-person in the future, that the leadership of the big health systems come together to help develop and advise on a global pandemic response strategy for the United States. We are the frontline. We are the troops on the ground. We are the battlefield. This is where we are where the battlefield will be. So we need to make sure that the leadership of the United States understands it, and that we not only complain about it, and not only say somebody else should do it, we’ve got to lead this effort. Just like I believe that we should be leading the effort on gun violence and not dealing with the Second Amendment, but dealing with the fact that gun violence is a public health issue. And the leadership of all the big health systems should be standing up and saying, gun violence is a health issue, a public health issue. We’ve got to be standing up taking a lead on it. That irrespective of how difficult and political it might be. Similarly, on the pandemic. We cannot sit back and, as the troops on the ground when these things happen, without making sure that the policies are there to back us up.

Gary Bisbee 31:23
Totally agree with that, of course. It’s now evident that public health is part of the national security. Michael, how do you think about it?

Michael Dowling 31:30
It’s funny you said that because I was talking to somebody else last night and I said, this is a national security issue. We got invaded by an invisible enemy. And more dangerous than so many others. This is national security. So we’ve got to look at it that way. And the battlefields are different. The soldiers on the field are different than our soldiers. But public health is fundamental strategy that the United States have to continue and each individual states have to continue to enhance their investment in as we go forward. As you know, Gary, most of the advances in health over the years came from the investment in public health – clean water systems, clean sewer systems, water supply – all are essential public health issues. And a pandemic reminds us in many ways about our vulnerability. We’re not as strong as we think we are. We count that back in January, February, everybody thought, oh, it’s wonderful – the economy is doing great, health systems are doing pretty well overall in general – and all of a sudden, overnight, this thing that we couldn’t see or touch, hit us and brought us basically almost to our knees. It will happen again. So we need to be sitting back now saying, “Okay, let’s put the plan together to make sure that when this thing occurs again, we are going to be prepared.” And every health system, by the way, one of the reasons for writing the book is to get other health systems and hospitals to say, you know, take a look at the lessons we learned. Put together the infrastructures in your system, that culture of preparedness that you need to have ingrained in your health system so you can appropriately deal with this issue when and if it occurs again, which it will. And not forget, you know and not a month from now say, oh by the way, this is over with, or whenever this is over with, and say, “Oh my god, that was a good experience we went through a couple of years ago. Let’s go on about our new business.” We can’t do that.

Gary Bisbee 33:27
Just following up the culture of preparedness. Social determinants of health is something that we’ve all spent more time on recently. However, historically, not so much. How do you think about that as a priority for our leading health systems, Michael?

Michael Dowling 33:42
Well, I’ll, I’ll talk about Northwell for a second. We’ve always been involved with this issue, but it was blatantly explained during COVID and that has now become one of our primary foresights over the next couple of years, is to work in those communities, working with people in those communities and organizations in those communities to help prepare them, provide the appropriate access to the right kind of care, invest in those communities. This also requires government to get very, very active. I mean, most of the health providers in many of these communities are completely funded by Medicaid. And hospitals in those communities, which I’m working with a number of them on right now, many of the hospitals in those communities are fully Medicaid. And they’re underwater financially. And the health systems working with government and working collectively, health systems together, to invest in those communities going forward. If we don’t do it, I believe, shame on us. And I don’t think there’s any magic wand that you can wave and that you can’t stand up and say, “You’ve only got to do these three things,” because every community is a little bit different. But in our case, this is going to be a major priority for us going forward. Right now I’m out in about 60 churches in those communities, working with the churches. And I toured one of those communities last week for what, three or four hours, and there are things that we will be doing there. And other systems have done some of this over the years like Kaiser Permanente and others and we can learn from each other. But we can’t just say, the systems are developing nice margins, doing all of these nice things and not invest in those communities. That’s not going to be a choice for us going forward, I believe.

Gary Bisbee 35:26
You’ve lived through September 11th, the AIDS Epidemic, H1N1, the Great Recession. How does this COVID crisis compare, Michael?

Michael Dowling 35:34
I think this is the worst that I think anybody’s ever seen, especially the degree to which it hit us here in New York. And one of the differences, first of all was, was the unknown. We didn’t know an awful lot about it. The other thing was though, when a hurricane hits, you know, it’s coming, let’s say on a Saturday and it will be over by Tuesday, right? And you may have a complete disaster during those four days and all those after effects, of course, would go on. And we’ve been through things like this. But with the COVID, we didn’t know whether this was going to last a month, two months, three months. The longevity of this first of all was enormous and the pressure it puts on staff and staffing 24/7, every day, from the beginning of March into June. Keeping people safe, keeping the morale up, maintaining their health and having the appropriate number of staff that can man the frontlines during a long sequence like this was the hardest thing. Most of these others came and went quickly. This came and stayed. And, of course, it may come back. This was different in for many, many, many perspectives. And, you know, I’ve been in the business a long time and my, many of my physicians have been in the business 30-40 years and they will all tell you unanimously that none of them have ever seen anything like this. Now there’s a lot of focus put on the number of people who died. We had in our health system, on many days, 90-100 deaths. But remember it the other way, we also saved tens of thousands of people. People died, unfortunately. It was worse at the beginning, but we got better as time went on because we know more clinically about how to treat it. But also keep in mind the tens of thousands of people that were treated and saved, that were transitioned out of the hospital to home. And right now we’re treating a lot of people that survived hospital COVID are now living at home, but have also got respiratory issues and other long-standing issues that many of them may have forever. So we’re studying all of that at the moment. So when people say, “I survived COVID.” Yeah, you got out of the hospital, but many people are going to have long term effects of COVID going forward and we’ve got to be well aware of this.

Gary Bisbee 37:58
So Michael, in terms of leadership in a crisis, what are the most important characteristics of a leader during a crisis?

Michael Dowling 38:05
Positive attitude; balancing reality with positiveness; taking responsibility; telling the truth – don’t sugarcoat it – but keep the morale high; and communicate, communicate, communicate; be visible. And those to me would be the major criteria. Let your troops know that you are with them and that they are the most important people in fighting the battle. But let them know by being with them. Say that as many times as you possibly can. I was on 60 Minutes at the beginning and I was asked this question about what the future would look like and I said, if I can recall exactly, I said something like, “This we will win. There is no such thing as putting up the white flag. There is no retreat. We are made for this. We will attack this and we will, at the end of the day, come out victorious. Staff need plebes. Unity is the other last thing I mentioned. Bringing people together as one to fight a common enemy. Like any good sports team, teams win. You can be fighting among yourselves when you’re fighting a common enemy. A leader has to make sure that we’re unified.

Gary Bisbee 39:24
Michael, you make the point in the book that some of the lessons that were learned were humbling lessons. How’s the COVID crisis change you as a leader?

Michael Dowling 39:32
I think it changes our perspective. I think it demonstrates that no matter how strong we’re pretty fragile and that your relationship with your co-workers, your family, your community is so important. In the midst of this, you realize that you are a cog in the wheel that you’ve got to make sure that you work as part of a community. We’re all interdependent. We’re all part of a feeling community. But I look at the world differently now. I also look at what we can do better in the future. We innovated, we’re creative, with enormous speed during the crisis. We had people working in areas that they never before worked in, the collaboration among the different disciplines was extraordinary. So if you take the team approach and that culture of what’s possible, the quickness of innovation and creativity, the unity of purpose, your perspective about your human nature in general, and you can bottle that. And you can carry it forward as we come out into a new normal over the next couple of years. And it can be a wonderful attribute if we can bottle it and have it help us all get better and better going forward. I don’t think, and I had a meeting earlier this morning with about 100 of our senior leadership and I said, I doubt that there is anybody in this room that has not been changed by what we went through. That we’re all a little bit different today than we were back in February. It may not be obvious immediately, but if we sit back and think about it, we’ve all been changed. And the public has been changed even though it’s never been involved in healthcare, because everybody’s circumstance has been disrupted – going to dinner, socializing, getting together with your friends in the community, all different. None of us are working the way we did before. It should make us feel about how fortunate we were when things were quote “Normal,” but also about what we have to do to secure our common health so if we do get back to a new normal, which of course we will, that we don’t lose sight of what’s important. And also, last thing, Gary, is the importance of healthcare. We know that they call them essential workers. The importance of healthcare and healthcare workers to the protection and sustainability of community health and the community in general was extraordinary. And that was demonstrated by members of the community, every night celebrating in front of each of our facilities, you know, fire engines and the police coming and saying thank you. All of a sudden, we became the most important people in the world to the people in the community, even those who used to criticize us in the past. We built up a certain level of trust. Our challenge going forward now is to build upon that trust and never again lose it. We have to do what’s right. And not just only do that which makes us look good. We have to do what’s right.

Gary Bisbee 42:38
Michael, we could go on for some time. We need to land here, but this has just been an excellent interview. To wrap up, Michael’s new book is Leading Through a Pandemic, published this month in August 2020. And for our listeners if you want to first hand account of the COVID 19 outbreak written from its epicenter, Leading Through a Crisis has many excellent lessons and stories. Thanks so much for being with us, Michael.

Michael Dowling 43:05
Thank you, Gary. It’s always a privilege. Thank you so much. And to everybody listening, I would say, stay upbeat and positive, the future looks bright.

Gary Bisbee 43:14
This episode of Fireside Chat is produced by Strafire. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review Fireside Chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we have found that podcasts are known through word of mouth. We appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capital in Washington DC, where we explore the intersection of healthcare politics, financing, and delivery. For additional perspectives on health policy and leadership, read my weekly blog Bisbee’s Brief. For questions and suggestions about Fireside Chat contact me through our website firesidechatpodcast.com or gary@hmacademy.com. Thanks for listening.