Implementation from a Leader’s Perspective
How do you get yourself motivated? What is your why with what you are doing? Join us as we continue our discussion about implantation… this time, from a leader’s perspective.
Cynthia Rojas 0:02
Hi, everyone. Welcome to Coffee Time with Masterminds. Last week we had a great show we talked about. We talked about what it takes to implement a new initiative. And there was a lot of conversation as there are many ways to go about implementing new initiatives, but by the end of the show, we realized that we just touched the tip of the iceberg. In this episode, we will continue the conversation, but this time from a leader’s perspective. Join us.
CTMM Jingle 0:41
Cynthia Rojas 1:06
All right. Well, welcome to Coffee Time with Masterminds, a 30-minute-conversations with and four leaders of mission-based organizations. We welcome our listeners in the United States, and Australia, and all over the globe. So, if you are here, join us. Please put your name in the comments and where you’re from. We always want to hear where you are located. I am Cynthia Rojas, and I am joined by my co-host today, Pieta Blakely. We have a guest Dr Alice Forrester, from Clifford Beers Community Health Center. I think, I said that right, Alice. Did I say that right?
Alice Forrester 1:51
Well, it’s Clifford Beers Community Health Partners, of which I’m the CEO.
Cynthia Rojas 1:55
Yes. Welcome. We’re so excited to have you. How are you Pieta?
Pieta Blakely 2:00
I’m great thanks, how are you?
Cynthia Rojas 2:02
I’m good and Alice, are you good?
Alice Forrester 2:04
I’m great and it’s so nice to be with you
Pieta Blakely 2:06
Thank you for coming.
Alice Forrester 2:08
I’m a big fan.
Cynthia Rojas 2:09
Thank you. We have a fan on the show. I love it. Well, Alice, we brought you in because last week we had an awesome conversation about implementation, which is something that many organizations seem to struggle with. At least, I get a lot of phone calls, like how do we begin something. Pieta is an evaluator, and she also gets a lot of organizations that are like, yeah, we need some data infrastructure, but where do we begin. So, it seems to be a hot topic with leaders, and so we thought, if there’s anyone who can talk about implementation, it is you. Let me just tell the audience what you and your organization have gone through or implemented. As CEO you are responsible for the implementation of four electronic health records. One, major accreditation process. You have experienced three episodes of hyper-growth, which was usually followed by new or redesigned infrastructure, and recently you implemented two centers for Medicare and Medic-aid services center for innovation grants. One in 2014 and one right before the pandemic in 2019. Can I just say, wow, all in one. Alice.
Pieta Blakely 3:41
It is hard for an organization to take.
Alice Forrester 3:43
Yes, it is. Actually, someone who used to work at my organization, Cynthia Rojas used to say, it’s like changing tires when you’re going 80 miles down.
Pieta Blakely 4:00
Yes, I once read a description of the big dig in Boston as like performing heart surgery while the patient is playing tennis.
Cynthia Rojas 4:20
I like that one, too. I like the goriness of that one because implementation can be
painful, but it can also be powerful and refreshing, and really it could be fun. It really could be fun. So yes, for our viewers, you may have heard Alice allude to. I used to work with Alice for many years, and so we have implemented many things together.
One of the things. Good morning, Mayra, thank you. Mayra says hi to Alice.
Alice Forrester 4:09
Cynthia Rojas 5:01
So, one of the things that we thought we’d start with is Alice, when you’re going to start something new and when you do something new, you go big. How do you get yourself motivated?
Alice Forrester 5:14
That’s a great question. I think the most important beginning, if you will, of an implementation or any work like this is you have to have the why. Why are you doing it.
I know you’re focused on mission-based organizations, and so for me the why is always
related to the mission. It’s related to the kinds of services we need to bring for our children family and adults that we serve. And so, it has to make great sense to be an improvement or moving the needle on social justice or social change. For me, it’s really something I’m able then to because I’m connected to the mission and because of the strategic growth that feels like a natural extension, it’s so easy to be excited about it.
Cynthia Rojas 6:18
Yeah. You have a fan, Alice. Odell Montgomery Cooper.
Alice Forrester 6:24
Hi, Odell. She is one of the most amazing women I’ve ever met. So, one day you have to actually meet Odell.
Cynthia Rojas 6:33
Welcome Odell. Because I think getting excited, as a leader is really the first step. Pieta, what are you going to add to that.
Pieta Blakely 6:45
That something underlying that is that you can clearly articulate how this initiative is contributing to the mission and convey that to other people. I think that’s
Alice Forrester 7:07
Yeah, and I think that’s a step sometimes we forget. You know, because again, the heart surgery and playing tennis. One of the things that Cynthia and I, did, early on, when we were moving to really a formal electronic health record. Cynthia, really laid out a communication strategy around why she had branded it. They’re still butterflies all around the clinic still from that time.
It’s sort of a change process and a weekly newsletter with games around the material around the electronic health record. There just was intentionality around the communication that I think was really extremely valuable. I do believe sometimes, especially when the change is in a siloed part of the organization like the CMS grants kind of occurred to the side, if you will because they’re so big and so tremendous and not yet impacting the day-to-day business. Sometimes people are like, why are you doing that. The people in the program know, but the people outside the program might not.
Cynthia Rojas 8:26
Yeah, and so, after you get yourself motivated, you then have to get staff motivated. Sometimes you’re running different implementations, right. You’re doing it simultaneously, so staff can be exhausted. And implementation usually falls above what we are already doing, so staff already have full-time jobs. What can leaders do to get their staff motivated to the point that they don’t create barriers. Because that staff can create real barriers to implementation.
Alice Forrester 9:05
Yes, they can, and so can we, as leaders. So, one of the things that’s been happening as we’ve grown as an organization has been to really see the critical role of a project manager. We were pseudo project managers, early on when we didn’t have any people who did it, right. And did a strategic, sort of, okay this roll-out. I remember our first rollout of NCTSN, and the trauma-focused Cognitive Behavioral Therapy.
We used to meet with people in the kitchen on Friday mornings and brought food so that people would come to the meeting, remember. And sort of use this pseudo focus group, sort of implementation team. But now that we’ve grown, having project managers who are actually managing the stages of the implementation is really critical. Someone’s got to have that spreadsheet, and someone’s got to be able to keep us on task. Who isn’t as invested in the actual change. Who’s not even involved in the change. That’s their job is managing the change.
Cynthia Rojas 10:25
That’s a good point. Who’s not so much invested in it, but invested in getting it done.
Pieta Blakely 10:30
Who’s invested getting it process, not the outcome. But you know, that rule is about facilitation. That if the facilitator is more than 20 percent interested in the outcome of the conversation, they can’t facilitate, right. You need somebody who’s interested in the process itself, not the result.
Alice Forrester 10:50
Right. When you’re small, though, you find yourself wearing a lot of hats. And I would agree. It was an interesting progression for me, as a leader. Well, actually, I was associate director for quite a few probably like three or four years, and I could implement no problem. But once I became the director or the Executive Director at that time, 13 years ago. I really couldn’t leave the projects anymore, and I failed at a few. That was why it was so helpful to have folks like Cynthia or other people who were really interested in implementation to come along and sort of manage that, if you will.
I never thought of it that way, but I think that that is a very true statement. And every time I try to poke my nose into the implementation, I cause so much trouble. I don’t mean to, but it’s like, what do you mean you’re not doing it this way, or you know, whatever, and because I am passionately interested in it.
Pieta Blakely 12:00
You know, another thing that I think we’ve touched on that really wasn’t sticking into a little bit more is that this new project is on top of people’s full-time jobs. And you need somebody who is not just going to be distracted by the day-to-day operations. Whose primary focus is on the new initiative to help people like you pull out of the day-to-day and pay attention to it.
Alice Forrester 12:35
Yeah. For example, we merged with an organization that has a community center and an 80-acre camp in a beautiful place in Connecticut. We also received, I think, something like two million dollars in bonding to restore the camp so it could be open. And the Executive Director, who’s now Vice President of Farnam Neighborhood House, has a great investment in the camp’s opening and probably knows how it looked before. He was very smart and allowed a project manager to handle the day-to-day contracting and operations where he could then focus on getting more contracts forced and grants for folks to actually come to the camp. So, that actually really paid off on both ends; they got to do what they do really well. It is a construction project; every implementation you need a contractor
Cynthia Rojas 13:46
Yeah, that’s a good metaphor. I think also that with. Oh my god, I lost my train of thought, which I do all the time, by the way. One of the things we did that you’re very good at Alice and is really important. Pieta, you and I, did not talk about this, last week. It’s this idea of vision. So, I was really big about visioning, and what’s really funny is that we had this vision of building a center that would have a waterfall in the lobby and every building would be all glass.
Every time we would walk into a building that had a waterfall, we were like, this is it, we have arrived. So, when I met Alice, I had like no vision capacity. I was extremely tactical, but visioning was important to the process. Like, how is life going to be better or different in two years because of this.
Alice Forrester 14:50
You know, it’s interesting. When I first became CEO, you might remember this. A guy who was a CEO coach for Folks in Their First Hundred Days, offered to kind of mentor me through. He mentored me much longer than the hundred days, but he taught me early on to pick one thing and stick to it. It was really clear, and he said, it has to be specific, measurable. He used JFK’s idea of not pre-eminence in space, but actually we’re going to put a man on the moon, at a very specific time. And you know, the man on the moon was the end goal. But what it did was, really develop America’s ability in science and all of the areas that it takes to get to the moon. He taught me that. And one of the things that I’ve chosen. I couldn’t say it this way, that we’re going to put ourselves out of business, out of the mental health crisis business. And that we were going to move into early intervention and prevention. A lot of people who were like, I’m not into that and left, which was fine.
They didn’t understand it, but I go back and I look at our old notes. I’m a very visual kind of pseudo-artist, so I draw a lot of things. And I’ve been going back and I’m like, yes, we did that. We didn’t we don’t have the waterfall, but there is a waterfall at Durham, in the in the camp. But we had drawn this wellness center for chronically stressed people. We would have a gym here, and mental health here, and the services, and a coffee shop. And everything we’ve done is adding on to that vision. You have to have a flexible vision. It’s not like it has to be this exact, but it has to have the general feeling.
Cynthia Rojas 17:07
Right, like it didn’t have to be all glass. We would have allowed a dry wall.
Alice Forrester 17:13
But at this point, I would take cement blocks less. So, you were always the very specific like, okay, it’s got to have the interior space, and all of them have a Feng Shui, or whatever. Personally, that has really kept me in the job for many years. You know, I’ve been at the agency for 25 years. And it’s that connection to the passion and the mission. Our organization is a little different than others in some ways because we have this hundred and hundred and ten-year legacy of a guy who had mental health issues. Who actually was treated for well, not treated, but locked up because of them. And he said, hell, this is not the way people should be treated.
When he left the institution, he wrote a book about it and changed the world. Everybody in Australia and all over the world knows that Clifford Beers was the father of the mental health movement. So, that legacy is really a cool legacy as an organization because he did it. He was mentally ill, and died mentally ill. I’m mentally ill, and I struggle with my own anxiety and depression, but you know what, I still can have a passion that actually helps lift me.
Cynthia Rojas 18:47
Yeah, and some people don’t get excited, and it’s overwhelming. So, how do you choose the person to lead it. Who becomes in your mind the person whom you assign this implementation project, too. What’s your thought process?
Alice Forrester 19:00
Well, remember when we first started doing the learning collaborative model because that’s been sort of the model that we use at the agency, all the way through, even today. So, in the learning collaborative, which is the institute of healthcare improvements model. There’s a breakthrough series where it literally is a visioning intention. This is what a wellness center for chronically stressed families would look like. We interviewed billion, you know lots of people all over the country.
What would it look like and we created a breakthrough white paper on that. And then, that was our guide post for our learning collaborative to be able to think about different areas to implement. One of the things is that, once you’ve determined the vision together uniformly with a larger group, you really look at early adapters. You look at people who really get it. Cynthia and I talked a lot about that. It may be a handful of people, and then there’s the middle of the road people who follow that handful. And then there’s always going to be a group of people who are not going to buy in. I think we learned to really focus on the early adapters and really give them the freedom to implement.
Cynthia Rojas 20:48
Yeah. Actually, many people tend to focus on bringing those who aren’t convinced along, right. The literature and research say, you don’t focus on those individuals. They’ll get off the bus; you focus on those who are willing and wanting to do that. And so, you leave those to figure it out. But your middle people, the people who are still your quote-unquote swing voters and those who are pretty sure they want to jump on the bus, are the ones that you focus on. Pieta, please jump in. I have a ton of questions for Alice. But Alice, you’ve done this when the organization was small, and you’re still implementing it when the organization is big. Which is easier, and how is it different?
Alice Forrester 21:52
It’s funny. When we’re not big enough because we’re still at that financial level where, every penny that is spent on back-office work is taking away from the actual direct care work. And also, the process of getting bigger is implementation too, right. I’m particularly struck by the phases of growth and how do you manage that. It’s not a project implementing implementation, as much as it is a culture implementation. I think, I feel, after having gone through this a few times, a little bit more confident that there is, it’s a phased approach. And that people at the beginning are the group therapists beyond used to say, there’s the storming, and norming, and pairing.
You know, group dynamics that happen, and then, gradually, the group forms. Living through all of those stages is very tough, especially again, as you’re doing heart surgery. I think, one of the things about growth has allowed us to hire people like process. Lashala Wells, who works for us, just was promoted to be a Director of Process Management. And really, process development, really understanding from the idea all the way through. We have a couple of folks who are hired as project managers. That is just an extraordinary beautiful gift to the organization to have people arguing that. So, as you grow, you can afford to have a little bit more people who are focused on the actual change management. But it’s complex, it falls apart. You go back, it, falls apart. Luckily, I have a background in improvisational theater, so I’m like, that actually is energizing to me. It’s like, oh, you have to go in a new direction, okay.
Pieta Blakely 24:12
How do you communicate along the way that it’s working? I’m an evaluator, so I just want to say something like, this is going to be a milestone and this is what I’m counting and measuring.
Alice Forrester 24:28
Yeah, it’s so hard and it’s so easy to forget to do that. It’s just so easy to forget, I think, to backtrack, right. You have to be very clear around your key performance indicators. What are they going to be. How will we know we’re getting to where we want to go, and that then takes a very tactical sort of approach to change. Again, when you’re doing heart surgery, you have to just rely on your skills in the moment, in the middle of playing tennis.
So, I do think that is very important and also the thing you forget to do. And also, you also make these weird thought processes of, oh, they don’t need to know that. Like, we often struggled, how much information should 200 people have about a project that’s going for 10 people like right now. I mean, all staff transitions like electronic health records and things like that really work on all staff communication. Unfortunately, if it’s done poorly, you don’t have to communicate anything because everybody had.
Pieta Blakely 25:52
What would you do if projects died. You know, you just never hear about it.
Alice Forrester 26:00
I had many projects die. I actually am sometimes the only person visiting those little graveyards of projects.
Pieta Blakely 26:12
Do you remember them?
Alice Forrester 26:09
That didn’t go. The cool things, though, are the things that actually you see over a long period of time. For example, we’re having a terrible problem with our revenue cycle management. To be honest with you, that’s what got me into the business was we weren’t getting collected for the for the units of service we delivered in terms of billing. The insurance companies weren’t paying us and I actually was outraged by that. I was just an intern, a psychology intern.
I was like, they should pay us; this is crazy. And so, I collected all the bills and boxes and brought them over to the insurance companies and said give me a price for this box. But revenue cycles continue to be an issue because insurance companies love to play hide the money, in various ways. I don’t mean anything but bad about insurance companies. It is behavior health billing is just ridiculously complicated. So, we have a revenue cycle team, um, and we’re working really.
Hard from a project management point of view to kind of hit those markers and I can.
They do have key performance indicators and so they are able to report out, okay, we’re there, we’re here. It’s a lot different than coming back with a ten-thousand-dollar check for the box you brought to the insurance company. I mean, that’s another yeah indicator, but I never knew I would be able to.
Pieta Blakely 27:56
Those kinds of things are internally so hard to communicate, right. I mean, it sounds really boring when you talk about your revenue cycles. You’re talking about keeping the lights on and being able to still serve the people right. It’s really fundamental, but the communication is a little challenging.
Alice Forrester 28:17
Yeah, and especially people who are mission-driven, they don’t want to talk about money. They become pretty focused on the work, which is really complicated and hard and awful. You know, it’s important. But I think communication can be soft, too. I think one of the most brilliant communication strategies was the one I mentioned earlier. when Cynthia did the newsletter and the word games about the electronic health record and the butterfly and, you know, really taking a soft approach to visioning.
Cynthia Rojas 28:57
Yeah, and one thing that I always appreciated that you did, which I think was effective, is because you’re visual. You’ve always had a whiteboard and you draw everything on the whiteboard. And then, you leave it there for months. So, everybody who comes into your office sees it and then you translate it on paper and you hand it out. Sometimes, even randomly, hey, look at this. And so, your teams are constantly looking visually at what you see, and I think that’s part of one the excitement, the two-part of the communication strategy that I think is important.
Pieta Blakely 29:38
It’s hard now, and a lot of people aren’t in their office or aren’t spending as much time in conference rooms. But we can’t overstate the importance of leaving things where people can see them. I mean, like visual reminders, if this is what we’re doing, this is why it’s important. I’m always telling clients like spreadsheets are nice, but why don’t you just put your important outcomes on some butcher paper in the front hall and remind yourself daily of your progress.
Cynthia Rojas 30:10
Yeah, I remember, and so we’ll end with this because I was thinking about it last week also and I didn’t mention it. We had someone come in as a consultant who was measuring, I think, the number of intakes. And, you know, we spent years talking about dashboards and the perfect colors and graphs and all this, and she was like, are you kidding. She took a white piece of paper and she typed in the number of intakes we were expected to do and the number we had done that day. I think, it was updated three times a day and it increased the number of intakes. And I think it was intake, so I apologize, it was something else.
Alice Forrester 30:52
No, you’re right, and it was on the front white board by the front desk.
Cynthia Rojas 30:55
Yeah, and it was that very simple. Pieta. Who would have thought we spent years talking about dashboards and she told us, you’re wasting your time.
Pieta Blakely 31:10
Yeah. The most effective data is the data you can see, right.
Cynthia Rojas 31:12
Yes, I love that. The most effective data is the data that you can see. All right. Well, Alice, I have to tell you. Thank you so much for really helping us see it from a leadership perspective.
Perspective, what it takes to one inspire yourself, but also inspire others. We have
Debra Miller said. “Thank you for this- as a board member of a community health organization, this is very helpful. And wonderful to hear my old friend speak.
Alice Forrester 31:45
Debra, I love you.
Cynthia Rojas 31:48
Alice has some fans. She has a lot of fans. We’re going to bring you on, again. Well, thank you so much, and thank you everyone around the world. We look forward to seeing you next Friday. Take care.
Pieta Blakely 31:58
Have a great weekend, everybody.
Alice Forrester 32:00
Thank you. Bye.
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