Healthcare Insights: Doctors as Leaders

When Dr. Nikki Cotler was a young girl, she visited the eye doctor, and in her telling of the experience, when she came out of that visit, “I could see”. Since that experience, she dedicated herself to become an eye doctor. 

Today she is a Doctor of Optometry and is the Director of Eye + Vision Services, practicing at NYC Health + Hospitals, Gotham Gouverneur, and an Assistant Clinical Professor SUNY College of Optometry. Through her position she is also a union member of the United University Professions (UUP). 

She spent many years in private practice, and in the course of her career she joyously became pregnant. At that time, she changed her work status from full time to part time. In that transition, within the last three weeks of her pregnancy, she became aware that she lost her health care coverage. In that experience, she learned vulnerability first hand. 

She sought and found full time work at NYC Health + Hospitals, the nation’s largest public health system. Through finding secure benefitted employment, she also began to serve a vulnerable population. Vulnerability was something she both understood from her own experience, and came to be the common thread of her patients and her service to them.

Dr. Morris Gagliardi, MBA, FACOG is the Regional Medical Director, NYC Health + Hospitals/Gotham, Manhattan, Medical Director, NYC Health + Hospitals/ Gotham, Gouverneur, and Clinical Assistant Professor, New York University School of Medicine. Dr. Gagliardi has had a wide-ranging career including the experience as a young doctor attending to patients during the AIDS crisis in the 1980s in Newark, NJ. Death and dying was impossible to stop in those earliest days of the epidemic.

After many years as an OB/GYN, he decided on a career in leadership and came to NYC Health + Hospitals to lead one of the largest diagnostic and treatment centers (DT&Cs) in the City of New York. These DT&C’s are the main entry point for primary care in the nation’s largest public health system.

He made the decision to join the public health system as a way of giving back. As the child of non-English speaking parents in Hoboken, NJ, he vividly remembers accompanying them to a public clinic and translating for them for their health needs. He saw that their immigration status was of no consequence as they were treated very well in the public health setting there.

Drs. Cotler and Gagliardi are practitioners and leaders at Gotham Health/Gouverneur. They chose public health to make a real difference on behalf of our most vulnerable populations. 

Gouverneur serves the Lower East Side, Chinatown, and the East Village in Manhattan, a very diverse population of more than 171,000 people. A brief synopsis of this population is:

1. 50.4% male, 49.6% female     
2. 60% identified themselves as Hispanic/Latinx, 7.6% were Asian/Native Hawaiian/Pacific Islander; 14.6% Black or African-American; 13.1% something else; 2.1% White; 2.3% did not disclose     
3. 64% of the patients spoke English, 27.2% spoke Spanish; 4.2% spoke Mandarin Chinese; 4.2% spoke other languages     
4. 6.3% were self-pay; 74.5% were Medicaid managed care, 16.2% commercial, 2.4% straight Medicaid; 0.6% other coverage     
5. The most common diagnosis: obesity, 14.3%. Other top diagnoses: asthma, 13.1%; developmental disorder 11.8%; depression 4.8%

The area of the city served by Gouverneur faces substantial Economic Stress:

While not the poorest neighborhood in the City of New York, between poverty, unemployment, and rent burden, the areas served by Gouverneur suffer substantial economic and social stress. Additionally, more than 75% of the patients seen at Gouverneur qualify for Medicaid:

 “Living in high-poverty neighborhoods limits healthy options and makes it difficult to access quality health care and resources that promote health. In the Lower East Side and Chinatown, 18% of residents live in poverty, compared with 20% of NYC residents. Access to affordable housing and employment opportunities with fair wages and benefits are also closely associated with good health. The Lower East Side and Chinatown’s unemployment rate is similar to the citywide average of 9%. Rent burdened households pay more than 30% of their income for housing and may have difficulty affording food, clothing, transportation and health care. Forty-eight percent of Lower East Side and Chinatown residents are rent burdened. One way to consider the effect of income on health is by comparing death rates among neighborhoods. “Avertable deaths” are those that could have been avoided if each neighborhood had the same death rate as the five wealthiest neighborhoods. Using this measure, 18% of deaths could have been averted in the Lower East Side and Chinatown. Many of the factors that affect health happen outside of a doctor’s office. This includes access to quality education, jobs and safe spaces to live. Residents in high-poverty neighborhoods often lack these resources. (Source: 2018 Community Health Profiles, New York City Health). 

As part of their professional lives, they also serve as leaders of the Gouverneur Facility Based Collaboration Council (FBCC). In other articles in this column, we have shared stories of these unique labor-management councils, established through collective bargaining between Doctors Council SEIU and the NYC H+H system. Each of the 21 facilities of NYC H+H have a Collaboration Council. 

In this column, we feature both the commitment and some of the defining characteristics of “Collaboration”, a term that in common vernacular has plenty of mixed messages. However, we know from the experience of seeking to improve performance, Collaboration is not a “nice thing to have”, but rather an essential element of enterprise success and high employee engagement. 

Moreover, it is inspiring and significant to appreciate the work of Collaboration inside the largest public health system in the United States, a system which cares for 1.4 million people, New York City’s most vulnerable.

What are the essential components of successful collaboration?

According to academic and practical study by Paul Adler of the University of Southern California, Charles Heckscher of Rutgers University, and Laurence Prusak of Columbia University as discussed in their Harvard Business Review article of July/August 2011, “Building a Collaborative Enterprise”, they both define and suggest the building blocks of a successful Collaborative Enterprise:

“A Collaborative enterprise encourages people to continually apply their unique talents to group projects – and to become motivated by a collective mission, not just for personal gain or the intrinsic pleasures of autonomous creativity. By marrying a sense of common purpose to a supportive structure, these organizations are mobilizing knowledge worker’ talents and expertise in flexible, highly managed group work efforts. The approach fosters not only innovation and agility, but also efficiency and scalability”.

The essential building blocks of this type of organization include:

• Defining and building a shared purpose
• Cultivating an ethic of contribution
• Developing processes that enable people to work together in flexible but disciplined projects.

On October 19, 2022, I attended an exposition of 22 performance improvement projects, most of which were undertaken by the Gouverneur Collaboration Council. From that remarkable visit, I began to dig into the reasons for the success. It became clear that Drs. Gagliardi and Cotler, along with their colleagues, had created the building blocks of a Collaborative Enterprise. What follows is that story.

The Collaboration Council at Gouverneur has been meeting every month since February of 2016. While the COVID-19 pandemic suspended meetings for a period of months, the Council at Gouverneur re-engaged through video conferences and continued their work with as little interruption as possible.

The Collaboration Councils’ establishment, through collective bargaining between Doctors Council and the City of New York and the public health system, sought to achieve improvements in both patient experience and doctor engagement. When the Collaboration Councils were launched in early 2016, there was much debate about which should come first: essentially, was it possible to improve patient experience without first improving doctor engagement? That question remained unanswered. Members of the Council at Gouverneur decided to hold a retreat in early 2017 to determine what would be a “shared purpose”.

After a very inclusive facilitated discussion by doctors from a broad range of departments and specialties, it was agreed that the shared purpose of the Council would be to improve “health literacy” of patients. This shared purpose led to a variety of projects designed to enhance the patients’ ability to understand their own health needs and how to access care. Such projects included making facility signage in multiple languages, translating notes and directives for essential services into several languages, and creating books with illustrations rather than words to communicate important information to enhance patients’ understanding of health challenges, treatments, and procedures to correct them.

The doctors began to see that their own engagement improved through the problem-solving process itself, a very common outcome of joint, patient-focused improvement work.

The doctors also developed consistent methodology to undertake improvement efforts. This methodology followed the Institute for Healthcare Improvement Model of Improvement:

With financial commitment from Doctors Council, video-teaching modules on the development and use of the above model was made available. Members of the Gouverneur Collaboration Councils attended these modules together and shared their learnings with the rest of the Council members at their meetings.

In time, the group outgrew the initial shared purpose of health literacy.

Through on-going discussion and further retreats, the shared purpose evolved into a broader sense of community across the facility. Through discussion the shared purpose included the establishment of strategic goals and sustained effort to achieve them. The strategic goals were summarized in the Mission Statement of the Council: 

“To provide out-of-office-hours opportunities for providers of all departments to meet and socialize, thereby strengthening engagement and communication as well as increasing joy during work hours, with a further aim of improving patient care and satisfaction in a more collegial workplace     ”

Specific Strategic Goals include:

• To practice and achieve “Joy in Work” which is defined as follows:

“With increasing demands on time, resources, and energy, in addition to poorly designed systems of daily work, it’s not surprising health care professionals are experiencing burnout at increasingly higher rates, with staff turnover rates also on the rise. Yet, joy in work is more than just the absence of burnout or an issue of individual wellness; it is a system property. It is generated (or not) by the system and occurs (or not) organization-wide. Joy in work — or lack thereof — not only impacts individual staff engagement and satisfaction, but also patient experience, quality of care, patient safety, and organizational performance. “What matters to you?” — enabling them to better understand the barriers to joy in work, and co-create meaningful, high-leverage strategies to address these issues. (from Institute on Healthcare Improvement, Framework for Improving Joy in Work, 20 University Road, Cambridge, MA 02138 Pirlo J, Balika B, Swensen S, Lacewell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org)

• To engage across departments and initiatives, including across service lines and the standing Quality Improvement Performance Improvement Committee (QAPI), the standing group in each facility that follows systemwide goals of performance improvement 
• The Collaboration Council has established standing committees:
  • Communications
  • Quality Improvement
  • Strategic Goals
  • Planning

These continuous efforts have led to a community of practitioners who share common interests and consciously spend time together. The group has become a learning community.

Some examples of Improvement projects that exemplify how the shared purpose of creating a learning community has led to improved patient experience and doctor engagement:

• Increasing Access to Ophthalmic Diagnosis and Monitoring of Eye Disease
  • Successfully increased percentage of testing performed per patient encounter from 30% to 50%
  • The business plan for the increased testing validated increased staffing costs by increasing revenue generation
  • Learned that the electronic medical records system supports the equipment and new workflow
  • Patient and staff culture change resulted in demand to maintain same-day access to testing
• Improvement of Physical Therapy Referrals from Podiatry department
  • Successfully increased number of referrals from Podiatry to Physical Therapy from 34-50%
  • Led to the continuous monitoring of referrals
  • Identified need to hire more podiatrists
  • Additional referrals led to inclusion in more insurance panels
  • Improved communications between podiatrists and physical therapists

***Data and outcomes show success in each project. Details are not shared due to the proprietary nature of the information as well as patient confidentiality.

“Being part of the Gouverneur Collaboration Council for the past three years has been a real pleasure professionally and personally. I’ve met and gotten to know colleagues here as well as from other facilities, and learned a tremendous amount about leadership and quality improvement. The Collaboration Council is a supportive forum for ideas to improve patient care and staff satisfaction by fostering quality improvement projects led by doctors and other staff.”

Rob Caldwell, MD, FACP, Department of Adult Medicine; Past Co-Chair, Gouverneur Collaboration Council*** 

***Dr. Caldwell is a leader of Doctors Council and was instrumental in the early development of the Collaboration Councils in 2016.

At this moment in the history of improving health for all Americans, especially its most vulnerable and disadvantaged by race, ethnicity, and poverty, while building the next generation of doctors, the Gouverneur Collaboration Council stands as a model for the development of doctor leadership and engagement.

We thank Drs. Gagliardi and Cotler for their time and insight for this article, as well as for their continuous leadership at the Gouverneur Collaboration Council.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.