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Physician coach Apurv Gupta discusses the article “What is a loving organization?” Apurv describes his model of a loving organization as a system that designs the clinical environment to make safety and purpose natural rather than forced. He explores the bridge between individual cognitive shifts and organizational renewal using the INTEGRATE methodology to reduce burnout and improve patient outcomes. By replacing fear-based operating systems with emotional literacy and compassionate accountability, medical teams can achieve high performance through unconditional acceptance. Discover how creating a workplace rooted in love can transform the health care environment into a space where both healers and patients thrive.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Apurv Gupta. He is a physician coach, and we are going to talk about the KevinMD article that he co-wrote with Michael Manell and Kim Downey, “What is a loving organization?” Apurv, welcome to the show.
Apurv Gupta: Thank you so much, Kevin. What a pleasure to be here.
Kevin Pho: All right, so briefly tell us a little bit about yourself and then why you decided to share this article on KevinMD.
Apurv Gupta: Yes, well, of course, I will start with the latter: why KevinMD? Why not KevinMD, right? KevinMD is the platform to get this kind of message out. So again, it is quite an honor. I am so glad that you accepted this article for publication. I think it is about getting the message out to as many physicians as possible.
As you mentioned, I am a physician as well. I am an internist. I worked as a hospitalist for many years. I was a medical director for a hospitalist group south of Boston, and then became chief medical officer at a couple of different community hospitals, also in the Boston region. Before coming into consulting for the last 12 years, I worked with a few different health care performance improvement consulting firms: FTI Consulting, Navigant, Guidehouse, and Premier. Over the years, I have cut my teeth in various forms of quality improvement, efficiency improvement, and operations improvement.
Over time, that brought me into the world of culture transformation, which is when we try to enhance our improvement activities by looking at how we engage physicians, how we make decisions, how we communicate, and how we hold each other accountable. That is the culture transformation layer, and we have generally found that when we are doing the work at that level, it makes our performance improvement work more sustainable and durable.
Over the course of COVID, I had a little bit of a wake-up call, really. I was doing this improvement and transformation work, and I started to feel that there was something wrong. Because if I was doing such a good job, then why were our people burning out like crazy? That really threw me for a loop. I just couldn’t connect the two parts; something was missing in our drive for excellence. We were driving the humanity out of health care. So that is kind of where this whole loving organization movement came about.
Kevin Pho: Obviously it sounds like you have been involved with many organizations. You are familiar with cultures from a spectrum of organizations. For those that didn’t get a chance to read your article, just tell us what it is about.
Apurv Gupta: The idea is that there is a growing movement, actually. For us, it was almost surprising because as I started digging into this question of whether somebody must have figured out how to deliver excellence without burning out people, we came upon a few organizations almost two to three years ago that were doing something different. They were taking better care of their own people. In that process, their people were reporting more meaning, purpose, and joy in their work. Therefore, they were actually more willing to engage in the work and more willing to collaborate. That was leading to incredible outcomes across the board: better quality, better safety, better patient experience, and even better profitability. It was not at the expense of the people, so their turnover rates and burnout rates were going down.
As soon as we saw that, it immediately struck us as what love would feel like inside an organization. So that is how we coined that terminology. What we have generally found now, Kevin, by studying these organizations—we are now up to 19 exemplars, as we call them, all throughout the country. They are not in any particular region. Some are large health systems, 50,000 people big. Some are 10-person clinics. Some are physician groups. Some are community hospitals. Some are faith-based, and some are not.
The commonality across all of them that we found is that they are taking the responsibility for being loving on the backs of the organization and not putting it onto the people themselves. They are not expecting Dr. Gupta and Dr. Pho to be more loving. What they are understanding is that they have an opportunity to make the overall culture and environment more loving by leveraging all of the systems of the organization. So that is the work we have done: to try to make those systems more visible.
Kevin Pho: Now for those organizations that you classify as loving, you said that they are taking more of that responsibility on the backs of the organizations. What are some specific examples of what that may look like?
Apurv Gupta: Thank you, Kevin. It is sort of continuing along the lines of what I had just mentioned. What we learned from these 19 exemplars is that we have reverse-engineered a methodology we call INTEGRATE. INTEGRATE is an acronym that stands for all of the systems of an organization. There are four people-based systems: leadership, teams, communities, and the staff themselves. Then there are five process-based systems: management, culture, technology, workflows, and policies. When you stack them all together, those are all the systems of any organization. It is just that by default, most of us don’t understand systems. We don’t see all of them; we just think about the people and leadership at most.
Our goal is to make all of these systems more visible. Our other hypothesis is that, again, by default we are operating these systems in a top-down command and control fashion, which is creating more fear. When you operate systems with fear, you get loneliness, burnout, anxiety, and depression as an outcome. In order to counteract that, again, what we are trying to help organizations and leaders understand is that you can make each and every level of INTEGRATE more loving. You can have more loving workflows, loving policies, and loving management.
You asked for a specific example. One of my most favorite ones at the leadership level is a system called cascading huddles, which Intermountain Health is the preeminent developer and distributor of. They start with a huddle at every bedside at 7:00 a.m. and they cascade that up to managers, from managers to directors, directors to VPs, VPs to presidents. By 1:00 p.m. every single day, the system CEO gets an update of everything that is going on throughout the organization. This is a quick communication mechanism to get everybody on the same page, to prioritize for everyone what the organization’s priorities are, and to ensure that the communication can be bilateral so that it is not just a one-way flow. When things get identified and fixed, that flow of information can go right back to the front lines. So that is an example of a leadership system, which takes leadership from sitting in one chamber at the top of an organization and distributes it throughout the organization so more people can be involved in determining what is working and what isn’t.
Kevin Pho: Now as you did research on these exemplar organizations, how did they get to be who they are? What were some of the decision points in their history that made them exemplars versus organizations that were, say, less so?
Apurv Gupta: I love that. Actually, no one has asked me that question, so I really love that. Thank you. That is getting right into the heart of the matter. I think that what led them there is probably not the same thing for every organization. At some of the organizations, what happened is that they were already on a journey towards excellence, and they were trying to amplify that journey by recognizing that they could deepen it.
Three of our exemplars are Baldrige Award winners: Southcentral Foundation in Alaska, Adventist Health Castle in Hawaii, and Sutter Davis Hospital in California. These are three of our exemplars, and they went on a Baldrige Award-winning journey, which is the nation’s preeminent quality prize. They recognized that in order to really solidify their operations through their culture, they needed to use a framework. They used the Baldrige framework to start pulling together and connecting the dots across the various operational and strategic things they were doing. Now you might say, well then why not just use Baldrige? Why invent something else?
Kevin Pho: For those who aren’t familiar with the Baldrige criteria, what are some of the criteria?
Apurv Gupta: The Baldrige criteria are really about seven different domains, and they are looking at things like leadership principles, management principles, and how well those are being implemented. They are looking at how well the operations of the organization are being systematized. That is the commonality.
There are other exemplars, like Baylor Scott & White Health, that have leveraged the Magnet principles, which is a quality award for nursing. One of the biggest things in that criteria set is shared governance, which means how do we get the people on the front lines to be involved in the decision-making of the organization. Baylor Scott & White has actually developed something like 17 interdisciplinary councils, which have now gone well beyond nursing. They include pharmacy, physical therapy, and even doctors. Now you can have rank-and-file staff, clinicians, and physicians all participating and sharing in what is working and what isn’t.
Of course, you can’t have 10,000 people participating. But these wind up becoming representatives, and so at least you are getting closer to the action, closer to the reality, so that leadership and governance don’t stay shielded from what is happening. We are not trying to make decisions in an ivory tower space. So that is the idea: you can leverage frameworks, and some frameworks can get you there, but the frameworks may not be sufficient. What we are trying to do through a loving organization is bring together some of the common thinking across these frameworks into the INTEGRATE model that I mentioned.
Kevin Pho: You mentioned that there are 19 exemplar organizations that you classify as loving and that there are so many benefits to that, like profitability, decreased burnout, and better patient outcomes. If there are so many wonderful objective measures associated with loving organizations, how come there are only 19 of these organizations across the country? Why is it so difficult for other organizations to obtain that loving culture and have those better outcomes?
Apurv Gupta: I think that is another really great question. There are probably many reasons. One is that the loving organization language and framework is all relatively new. People are just hearing about it. That is why we wanted to get it out on your platform, have this podcast, and send the message out. We think more and more people need to hear about it. We have just created a not-for-profit group called the Loving Organization Consortium so that we can bring together like-minded people who can talk about this and spread the word. The goal right now is to create thought leadership, create awareness, create a brand, and make people understand that there is an option.
Prior to this, these organizations were already doing the work. It is not like they were waiting to do the work; it is just that we had no common language or way to refer to it. So that is really what we are creating: a common way to think about what all of these organizations are doing, and that needs some time to spread so more people can hear about it. So that is one challenge: we think there is more of a knowledge deficit.
The other challenge, which I think your question is really getting at, is that it is not so easy for people to just say: “Yes, we will be loving.” In many cases, people feel “love” is too strong a word. Is that really what we want to do? Do we want love inside our organization? A lot of people resist that sort of thinking. It is not like you’d say love and everybody would be all open arms. There is a lot of fear about love, and we are trying to help people understand that the kind of love we are talking about is the kind of love that can actually get things done. It is necessary love, without which the systems become very sterile. You can get operational efficiency, but if you do it without love, it just feels like extraction. It feels like overwhelmingness or work overload, and ultimately that is what leads to burnout.
We are trying to help people understand that love has to be a necessary part of the systems. We have all implemented many, many kinds of systems like Lean, Six Sigma, and PDSA, and unfortunately, inevitably we find that at some point those systems may not work if they don’t take the human element into account. It is that recognition of the necessity of the human element that we are trying to bring.
One specific thing that I think we get a lot of pushback on is the idea that if we are loving, we won’t be able to hold our people accountable. That is a key management paradigm that we are trying to help people understand. No, in fact, being loving is being accountable; it is being able to hold each other accountable. It is expecting the leaders to hold the workers accountable, but the workers still hold the leaders accountable. We call it mutual accountability. Without accountability, we can’t actually produce, move things forward, hit targets, or do work. We are here to work; we are not just here to be loving.
So I think those are some of the barriers that people have. One is a lack of awareness that this is a possibility. Two, even when they do know, they don’t think that it is a necessity for them to incorporate. Three, they also feel that if they did incorporate it, it would actually make it more difficult for them to do their work rather than making them more effective.
Kevin Pho: Hypothetically speaking, and I am going to put you on the spot here. If an organization that was, for lack of a better term, fear-based wanted to come to you and change their culture, how would you get started? What would be some ways they can start? Because like you said, it is very difficult to change a culture within a medical organization. What are some ideas on how they could even get started on changing that course?
Apurv Gupta: Again, thank you, Kevin, for asking that. I think I would say it is first a recognition that we are all fear-based. All of us are operating at some level of fear. So it is not an “us versus them” situation in that way. Fear actually winds up being a great equalizer. Management is operating through fear. Physicians are operating through fear. Nurses are operating through fear. We are all operating that way just because that is the way we have been acculturated, that is the way we have been brought up, and that is our society. We just don’t even realize it.
First is to recognize that fear is just the common milieu, and there is something we can do about it. So that organization coming to us is already a great sign that they are starting to open up to the idea that maybe there is something else here. Maybe we should be thinking about different, more humane ways to manage that will actually get us to be more productive and efficient, but also take care of our people at the same time.
The very next step that we usually would recommend when they do come to us is to start with an assessment, like any good consultant. After studying these 19 exemplars, we have understood some of their best practices. We have converted those best practices into a maturity model scale of one to five for every level of INTEGRATE: leadership, teams, community, and so on. We can apply that into an assessment format, which we can take to any organization and say: “OK, after talking to some of your leaders, potentially to some of your staff, and some of your physicians through focus groups, we can help you understand what your strengths are as a loving organization currently, what your challenges are, and what opportunities exist with respect to the best practices that we have seen at these other 19 exemplars.”
We then give you an assessment report out, which will tell you exactly what you need to do to get better. On leadership, can we implement a shared governance mechanism that we discussed, like Baylor Scott & White? Could we implement a cascading huddle system that would get us from where we are at to the next level? Those solutions really have to be customized from where people are at. People could be at the beginning stages of the journey where the fear feels stronger.
There we would probably say the journey has to start with just a handful of leaders. If you can get even three or four of your leaders on board, starting to understand what it means to practice in this way—a more loving leadership style—then that can start to create the momentum required to start thinking about how to create loving workflows and loving policies. Not every single person in a loving organization needs to already be quote-unquote “loving” at the outset, but a few select leaders certainly need to be there. Across the 19 exemplars, we found that there was at least one such leader, and in some cases, it was the entire senior leadership team. It is somewhere in between, but some form of activated leadership is required.
Kevin Pho: We are talking to Apurv Gupta. He is an internal medicine physician, physician coach, and consultant. We are talking about the KevinMD article that he co-wrote, “What is a loving organization?” Unfortunately, Kim Downey, who was the one who connected us, couldn’t be here today. She did send a message that she wanted to share, which is that we need to bridge individual well-being with system design. We need to replace a culture of fear in medicine with psychological safety, support, and connection up. However, I am going to let you also share your take-home messages to the KevinMD audience.
Apurv Gupta: Thank you, Kevin. I really appreciate that, and thank you to Kim for introducing us and providing this platform. I think my take-home message to the physicians on this platform is particularly: Don’t lose hope. I know many of you are struggling, feeling burnt out, disengaged, and feeling despair. What I would say is to ask yourself this question: Wouldn’t you want to be working in a loving organization, and wouldn’t you want your patients to be cared for by a loving organization? If that appeals to you at any level, then come and join us. There is strength in unity.
Come and check out our website, www.alovingorganization.org, and under “Free Resources,” you will find a clinician manifesto that we would love for you to sign. We are looking to gather up thousands of signatures to take back to health system leaders and help them understand that there is a need and a demand for this kind of work, and that their physicians are asking for this. In that way, you could convert three minutes of your time into something that could really make a big difference around the country and actually around the world.
Kevin Pho: Thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Apurv Gupta: My pleasure. Thank you, Kevin, for this opportunity.
