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'A first like no other': WellSpan’s CEO on reimagining health care—and leading through crisis

Welcome to the "Lessons from the C-suite" series, featuring Advisory Board President Eric Larsen's conversations with the most influential leaders in health care.

In this edition, Roxanna Gapstur, Ph.D., R.N., president and CEO of WellSpan Health, talks about how the COVID-19 response has irrevocably changed the system, why vertical integration is a necessary “battle,” and how taking the CEO position has defined a "career of firsts."


Roxanna Gapstur, Ph.D., R.N., president and CEO of WellSpan Health

Question: Roxanna, you took the helm at WellSpan, a $2.8 billion, 20,000-employee integrated delivery system in South Central Pennsylvania, just 15 months ago, following more than a decade of work with HealthPartners in Minnesota. I'd like to learn about this transition, understand your strategy for 2025, and ask your thoughts on navigating the shift to value-based care in a fee-for-service environment, among other topics—but I'd be remiss if I didn't ask you first for an update on where you are with COVID-19.

You offered a very insightful snapshot of your system during this crisis when you sat down with Steven Berkow a few weeks ago. How have things developed since then?

Roxanna Gapstur: We've seen a real flattening of the curve here in central Pennsylvania. We expect to have some ebbs and flows over the next several months to 18 months, but we don't at the moment expect that we'll see a massive surge of patients.

It's probably the best-case scenario for us in central Pennsylvania in that I don't think we'll be overwhelmed—in fact, we're lowering our command center levels gradually and pointing our ship toward recovery.

Systemness resources

Q: Understanding that we're still in the midst of it all—and we don't have the benefit of six months of hindsight—how has the pandemic affected your system?

Gapstur: One of the most powerful changes has been enhancing systemness. From a big picture perspective, before COVID-19 happened, we were on the journey toward an operating company approach, but we weren't leveraging all of our assets together. We'd established a team—who actually worked with your company to rework our leadership team into a regional structure—to focus on putting our systems together. But then COVID-19 hit, and that placed a microscope on how we work together.

At the end of February, when we knew this was going to be an issue, the very first thing I did was establish our first system command center. At the start, we focused solely on the system; we didn't even open our entity-level command centers for two weeks. But once we understood how it could work efficiently, we opened up our incident command centers for execution in our regions, and everything was coordinated at the system level with twice-daily command center calls. I'm proud to say that it's just worked beautifully, Eric.

As a result of this reconfiguration, we've been able to leverage our resources, move ventilators and personal protective equipment (PPE) around as needed to areas of our organization experiencing higher patient volumes. We've redeployed thousands of staff to different roles. We went from having 300 people working from home to more than 4,000 people working from home—all in just one week. We've been able to execute so quickly because we worked as a system versus parts and pieces.

Q: While this crisis has clearly accelerated system cohesion, how is it affecting the pace and extent of the move to value? I ask because some of the early speculation is that COVID-19 and its aftermath may prove to be a decelerator to value-based care conversion, especially as a liquidity- and solvency-crisis has emerged for some systems in the past 90 days.

Gapstur: Maybe I'm in denial, but because our market tends to lag, it won't change things for us drastically right away. Then whatever happens in the rest of the country will catch up with us—and, of course, the federal aspect will be important for all of us to be cognizant of as we continue to see how this all works. My hope is that we can keep going with the payer partners we have and the work that we're doing.

Q: That's fair. And, of course I hope the speculation on this is proved wrong.

Gapstur: I hope so too, but I don't disagree with the perspective, Eric. However, I think this market is unique in that we're really under-bedded—two of our six acute-care hospitals were probably at 100% and the others between 80-85% beforehand—which is good in a time like this because we've talked quite a bit at our organization about how we're not acquiring any more hospitals.

What we are looking at, though—and one of the things I think we will do in the next three to four months—are some deals we're moving forward with ambulatory and physician groups. We're going to be focused in that sector, and that is where we were most aligned with our payers here in South Central Pennsylvania as well. They are very interested in working with us on risk arrangements within additional groups.

Our physician group is composed of 1,600 providers, but we also have the WellSpan Provider Network, which has about 2,700 providers in total, including ours and about 1,000 independents. Now, these groups I'm talking about actually aren't in that network, yet. It brings us really close to 3,000 providers, which will be a great physician group to have for our area -- and by far the largest outside of Pittsburgh.

From HealthPartners to WellSpan

Q: I'm keen to explore this strategic shift you've described further, and parse out the implications for your pivot to value, but to first set the groundwork can we rewind a bit?  I'm curious to hear what brought you from HealthPartners, where you served as SVP, to WellSpan.

Gapstur: You know, it's an interesting story because I was not looking for a job. I loved my position at HealthPartners; it was fascinating to work in both care delivery and health plan services. Recruiters would often send job descriptions my way and I'd give them candidates.  But this time the recruiter said that I should really consider the role—and that's when I learned that WellSpan was an organization hungry to take the next step toward affordability, quality, and the triple aim.

I found that stance really fascinating, because it wasn't something the system needed to do—you know, South Central Pennsylvania did really well on fee-for-service, so WellSpan could have stuck to that path for many more years. I was attracted to the idea that I, coming from a leading market to trailing market, might have something to offer as a leader for that transition.

Q: HealthPartners, of course, is one of the most sophisticated, vertically integrated payer-providers out there. And to me, the definition of being truly vertically integrated is that you don't have fiefdoms; you've figured out how to subordinate what's good for the individual P&L (be it acute, insurer, ambulatory, etc.) for what's good for the whole organization. So what are some of the big learnings from being part of one of the preeminent vertically integrated systems, and how are you beginning to apply those to WellSpan?

Gapstur: I absorbed a lifetime's worth of learnings at HealthPartners. It was such an eye-opening experience—but it took time, Eric, for myself personally and for our organization as a whole to really understand the benefits of integration. I think it really came down to great leadership at HealthPartners—fantastic people like George Halvorson, Mary Brainerd, Andrea Walsh. Their culture and standards of integration is what made that work.

And I agree with your view on the definition of vertical integration.  As a senior leader at HealthPartners, there was an expectation that you viewed the whole—the health plan and care delivery. It's one of the only organizations I've ever seen that functions like that; usually there's the organizational CEO and then the health plan CEO, but at HealthPartners, there is just one CEO. That meant all of us at the CEO table had both health plan and care delivery to consider—if you were sitting at the table, you didn't have the option of saying, "Well, I work in the hospital division, and this is how I see it." That speaks very loudly in an organization. 

Q: That's important, because even when I look at systems I consider deeply integrated, like Intermountain, they still have a CEO of the health plan.

Gapstur: Yes, it can become, "This is us." There are times when it's difficult, of course—times when you wish we didn't have our plan this year, or that care delivery would, you know, drop off a cliff because things get tough. Eventually, you understand the benefit of the health plan having a bad year when care delivery is having a good year, and vice-versa. That balance of the P&L is extremely helpful.

I really came to appreciate the benefits of having both. You get the strengths of both, the analytics, the population health competencies—all the things that you wish you had more of in care delivery because you can better serve patients. You have that in a vertically integrated organization.

Q&A on Lessons from HealthPartners

Q: Roxanna, your description of a high-functioning vertically integrated system is compelling.  The challenge, of course, is ‘getting there'.  The history of providers establishing their own plans has been a messy one.  Between 2010 and 2015, providers launched or acquired 37 provider-sponsored health plans. At the end of that period, of those 37, only four were profitable (achieving those aspired-to benchmarks of 50,000 commercial lives or 5,000 MA lives), five went out of business, and two were sold.

Zooming out across the industry, the success stories here took a long time to figure it out – the health plans of providers like Sentara, Intermountain, and Presbyterian (New Mexico) have an average ‘age' of 18 years.  So I'd like to ask, Roxanna, how important do you think it is it for a traditionally care delivery-centric organization to develop a health plan function? In other words, does WellSpan need a health plan?

Gapstur: Eric, I think it is necessary. Having come from that environment, you have so many advantages you don't even really realize while you have them—there were just things at HealthPartners we didn't worry about at all because we knew we had them.

We knew we had claims data and Epic data merged together for predictive analytics; we knew we could predict who was going to come to the ED so we could reach out to them ahead of time. And when you don't have those advantages, you see the glaring discrepancies. I think for those who don't think it's necessary, that's probably just because they don't know what it looks like.

Q: And since WellSpan doesn't have that health plan function yet, how are you thinking about creating that proficiency here—make, buy, partner? What's the shortest distance from ‘here to there' to replicate those capabilities and benefits?

Gapstur: Honestly, I think the shortest distance from here to there when it comes to achieving the health plan function would be a vertical integration. The time may be right for that in the next couple of years; it's something we've thought about as an organization. I think we will continue to wrestle with that over the next couple of years and move closer to stronger partnerships with the payers, whether it's the payers who are here right now or ones not yet in our market. I don't think it's going to be possible to be vertically integrated without both parts of the business.

Q: This may be a good segue to ask about your partnerships with Capital BlueCross and Highmark. Would you talk about your approach toward collaborating with payers?

Gapstur: Well, I don't think you can't really come from a leading market into a transitioning market and just take those competencies and exactly replicate them. That doesn't work. In a very much fee-for-service environment, the payers don't have much incentive to change toward value.

In this first partnership with Capital BlueCross, I tried to emulate some of the things we'd done years ago in the Twin Cities, which was to make long-term agreements around aligning our interests and then innovating together to create more affordable, higher-quality outcomes—I think it's a very non-threatening way to move toward value. We have an eight-year contract with each other, and within that agreement, we commit to moving into risk together in Medicare Advantage and commercial, ACA, other products, etc.

Another thing we've started to do is dig in on the innovation side. In the Twin Cities, we'd do this by having retreats with our payer providers, taking a day to talk about, "What are the best ideas we have that are new for in care patients that we can't get paid for right now? How might we make care more affordable?" Now we're doing that here, and it's been very much welcomed by both Capital BlueCross and Highmark.

Q: It doesn't surprise me that you're focused on doing things differently with your payer partners – I know how passionate you are about partnerships and innovation.  Shifting topics a bit, are there other examples of innovation at WellSpan that you're particularly proud of right now?

Gapstur: We actually just received the John M. Eisenberg Patient Safety and Quality Award in the category of Local Level Innovation for WellSpan's Sepsis Central Alert Team program. The team is a group is RNs with critical care and emergency medicine experience who continuously monitor patients for signs of sepsis at five of our hospitals from a remote “bunker.” The team is notified when the EHR system detects symptoms of sepsis in a patient's vital signs, including temperature, heart rate, and lab results. When the team receives this notification, they can determine if the patient might be septic or clinically unstable and make appropriate care decisions. It's a highly effective combination of real-time electronic healthcare and a highly skilled clinical team—they've saved 350 lives in just three years. It's really incredible.

Comparative markets

Q: Roxanna, let's compare, for a moment, the different competitive landscapes between Minneapolis/St. Paul, and here in Central Pennsylvania. For the Twin Cities, everybody is a "pay-vider" (M Health Fairview, Allina and HealthPartners all have health plans); and over the past decades, the market has been widely regarded as highly collaborative (shared ACOs between competitors, etc.).

I think we can agree that Central Pennsylvania, is, shall we say, less collaborative.  To call it highly competitive is more like it – very well-capitalized, super-regional systems with traditional market borders shifting quickly, and one of the more rapidly consolidating geographies in the country relative to how unconsolidated it was before.

Now, these are admittedly oversimplified descriptions, but do they broadly feel right to you? How would you juxtapose the competitive dynamics here?  

Gapstur: Yes, absolutely. Well, I love the Twin Cities; I'd feel comfortable taking my family to any hospital for care. That's something you don't have in every city in the nation—and I think that's what leads to this sort of collaborative milieu. It's really the respect people have for each other's organizations and the knowledge that those organizations have such great quality. That really helps competition there—and it is competitive.

But you're right, it is very different here in Pennsylvania. Not only is there some variation in quality, but until recently, it hasn't been as competitive. For a long time, WellSpan had a large system and then there were some smaller organizations. Over the last three years, very large competitors started coming in on both care delivery and health plan to stake a claim in this part of the country.

It's made the market more competitive, but that's been a good thing—everyone raises their game when the stakes are higher, and that will be good for consumers. Now, whether it will lead to more affordable care, that's a question that's still out.

Q: I think that's well-characterized. And the other dynamic is that the traditional designations of geography in Pennsylvania are becoming less relevant, especially with Pittsburgh competitors coming right on the border of Philadelphia and, as you just mentioned, folks from further geographies—UPMC, Geisinger, etc.—coming into the market. It's heating up.

Gapstur: It is. It's very disruptive. When I arrived, my board was very worried about some of the competitors coming into the market, like UPMC and Highmark. I tried to assure them that this isn't going to flip in a year; competitive changes usually don't happen very rapidly, unless something really cataclysmic occurs.

So, yes, we need to be very conscientious about how we go forward. We have to have a smart strategy, we have to have a great brand promise, and we need to fulfill that brand promise—but so do they. Keep in mind, too, that we're a pretty financially healthy organization. So we're not just going to flip over and that'll be the end of it. I think when you're not used to being in a competitive market, you sometimes think, "Oh no, the competitors are here, we're all done now." But it's not like that.

Q: Well, in every other industry, competition leads to lower prices, higher quality, and better customer service.  But in healthcare, paradoxically, competition has led to less competitive pricing and less affordability. But somehow you figured out how to do it in the Twin Cities so I'm hopeful that some of it will rub off on South Central Pennsylvania and beyond. 

Gapstur: Me too. As you can imagine, it's a hard ship to turn because getting traction on affordability in organizations that haven't necessarily lived that culture takes a bit of time. But so far, I'm feeling encouraged.

Defining value

Q: It's clear, Roxanna, that you're approaching this with a value-based mindset, so before we touch on WellSpan's strategy going forward, I'd like to step back and really just define the term as you use it in your system. Because to me, real value-based care isn't shared savings – it reaches into delegated risk and capitation. I'd be curious if you have a different or a graduated definition around that.

Gapstur: That is a great question, Eric. You see, there really isn't a measure in Pennsylvania; each payer here has its own internal measure. We're working with our Analytics Center of Excellence to understand what will be the best measure for us and how we can use it with multiple payers. The payers are open to it, too, because we need a measure to ensure that we're improving, that the per-capita cost of health care is coming down, and that we're passing those savings along to our communities.

My definition is capitation, decreasing the per-capita cost, the triple aim—that's really what it is.

Q: It's interesting to hear the vocabulary that you use around total cost of care (TCOC) and per-capita costs, because I think it speaks to the fact that you are ‘bilingual' with both payers and providers, which can be a benefit to breaking the logjam of traditionally adversarial and contentious payer-provider negotiations.

You mentioned the board was very much interested in a shift toward value when they hired you, but were they defining that as you do—as downside risk, as a synthetic sort of vertical integration?

Gapstur: Before I came, the board had spent a year and a half talking through where the national landscape was going and the regional landscape. They kept coming back to this idea of affordability and value as being very important for the future.

The measurement of value, though, can be tough to define. Now certainly, they knew about downside risk because they were part of the Medicare Shared Savings Program (MSSP)—even though it was an upside-only model, they knew there were models that included downside. So I think it was probably a question of, "We know what we want to do, but we don't know how to get there."

I've seen tremendous change in our organization just in 15 months, and I know 15 months from now, there'll be even more, and we'll be measuring our results—we'll understand if we've actually lowered the TCOC in our communities. That's very important to our board and to all of us. That's the metric we're holding ourselves to.

Q: So you've come from a TCOC mindset, and obviously that's going to be prominent in how you advance your 2025 strategy. But the payment hydraulic for WellSpan is disproportionately fee-for-service, so it's not necessarily incentivizing this shift. How are you reconciling that?

Gapstur: It does drive me crazy, Eric. It's a slow process of change and it takes patience because I have to be realistic about what we can accomplish each and every month. But we'll get there.

One thing from HealthPartners that I would say has been very helpful for me is I know how hard this is, even in a vertically integrated organization; it's a battle day in and day out. It's a journey, and it's something you're constantly working on. That's just the reality of it.

Q: Roxanna, we've touched on some of the big structural themes—the movement to risk, affordability, and the partnerships you're building with payers, etc.  I'd like to zoom out a bit and to hear you articulate the strategy more comprehensively. Keeping in mind how you're defining value, what does that shift look like in terms of WellSpan's 2025 strategy?

Gapstur: As I mentioned, the board had this idea around value, but nothing was specifically articulated. So we set a new vision based on answering the question, "If we had a North Star, what would it look like?" This was big, because WellSpan hadn't actually had a vision statement for many years.

We ended up with, "A Trusted Partner. Reimagining Healthcare. Inspiring Health." It's all about value, and it felt very aspirational, because we weren't a value-based organization yet. But once we had the North Star, we then developed a triple aim strategy based on four key pillars: engage, innovate, deliver, and thrive. And these pillars—especially innovation, which we didn't have as an official function previously—are aimed at helping us figure out how we will stand out and what that will look like.

Q: I know you have a healthy impatience about moving things forward quickly.  But I also know that how important organizational culture is to you, and that isn't something that one can change organically overnight. Can you talk about how the culture has adapted to this shift?

Gapstur: Originally, the culture was rather traditional for health care—very mission-driven, focused on community, but in some regards, kind of complacent, probably not very agile, because of that fee-for-service environment. What we want with this shift toward value is more agility, more highly reliable care, more innovation, more customer focus; these are the things we have to enhance to evolve our culture. We are also working on figuring out how we can act more like a system, because we'd grown so quickly that we were more like a loose federation than an operating company.

Honestly, Eric, as we touched on at the start of this interview, COVID-19 has accelerated this shift; we've been more agile, more innovative, and we've acted more like a system in the last eight weeks then we could have hoped to be in two years.


Q: Since we're talking about what trends this crisis may accelerate or decelerate, I'll ask about two domains we've yet to touch on—telehealth and behavioral health services. I'll start with telehealth, because WellSpan was already focusing on virtual access prior to COVID-19, but the uptake has gone sky-high in the past few weeks.

What are your takeaways from this experience? How has COVID-19 accelerated your telehealth capacities?

Gapstur: Before COVID-19, we were doing a couple things with our digital platform—we used TelaDoc for online urgent care, and we'd just expanded that to include primary care, too—but, to be honest, we were having trouble with adoption. We had six ACO practices participating, and between mid-February and Mid-March, just 12 providers actually completed a video visit. So it was clearly a bit half-hearted.

Then COVID-19 hits—we went from 180 visits a week to 20,000 a week in just about a month. When you compare the four-week period from mid-February to mid-March with the four-week period from mid-March to mid-April, we went from six practices to 238 practices, from 12 providers to 870, and from having about 0.4% of our outpatient visits completed remotely to having 47.2% of them happen remotely.

Q: Wow.

Gapstur: And here's another amazing acceleration. For all of our employed physicians, we have centralized scheduling and an online self-scheduling option. Our patients self-schedule 30% of our primary care and specialty visits. We've found that the no-show rate for self-scheduled appointments is half of what the no-show rate is normally.

Since COVID-19 hit, we've been allowing patients to schedule their own video visits—in just one week,we had almost 800 video visits scheduled by patients.

Q: It's impressive how quickly you were able to leverage that virtual domain. What was the strategy for adoption here?

Gapstur: I'm really proud of the team for this. At the start of our pandemic response, we began hour-long phone calls at noon three times a week—Monday, Wednesday, and Friday—with our WellSpan providers and any independent providers who'd like to join, and we go through how to conduct video visits---tip sheets, equipment, all of the details.

Q: I know it's too early to tease out the structural shifts post-COVID-19, but how are you thinking about your virtual strategy after this is over? Virtual care has jumped forward in its adoption by a decade during this pandemic, and is here to stay.  And candidly, I think this process, despite a perhaps bumpy initial user experience, is going to teach consumers that they can engage with the health system in this way, and that the way they've traditionally engaged the health system – in person – will shift.

Gapstur: You know, we have a team that's figuring out what recovery will look like, and one of the biggest things they're wrestling with is getting virtual care here to stay. We think it's the better, more affordable option in many instances—obviously, some patients need to come into the office, but there's so much that can be done virtually.

Our physicians have seen it, our APPs have seen it, and I know our payers, who are so interested in this, will work with us to make it happen. And my goodness, if we look at the kinds of things has COVID-19 accelerated, I have to hope that in this way it has accelerated affordability a little bit.

Behavioral health services

Q: Now, adjacent to that is mental health, because one of the other things that's become undeniable is just how the stress level is increasing. It's just one metric, but it is concerning how the number of prescriptions, anti-depressants, and anti-anxiety drugs is up 30-50% in the past few weeks.  This crisis is yet another urgent reminder of the centrality of behavioral care in our system, and it is showing up some of the cracks in access. 

WellSpan was progressive in this with the 2016 Philhaven behavioral health organization acquisition, which I'd love to hear more about. Overall, though, how has COVID-19 affected your behavioral health services?

Gapstur: The Philhaven acquisition made us the most comprehensive behavioral health organization in central Pennsylvania. When Philhaven joined our organization, they were the 14th largest mental health care provider in the country, so we're big—we have nearly 400 behavioral health providers. We provide not just inpatient care, but also a range of outpatient care options in 65 locations across our whole footprint. This is a part of who we are.

Before COVID-19, we began something called Shared Care, which integrated behavioral health into primary and specialty care virtually and by phone. Our primary care specialists could get a curbside consult as needed, but we could also do virtual patient visits. Now, of course, that's much more robust, since—just like the rest of our care—it's pretty much all virtual now. In fact, our video visit volumes for behavioral health services increased by 30x between March 15 and April 12, going from 172 video visits to 5,010.

Q: This proactive integration of behavioral care into the care continuum is really the province of highly integrated vertical players—I know HealthPartners had a very robust integration in this space as well. I think it's going to situate you advantageously in a post-COVID-19 world. Would you describe what that behavioral-primary care integration looks like as a program, and what you're hoping for it going forward?

Gapstur: Our Shared Care teams have a mix of players; we'll have a PCP group and then a behavioral health team working specifically with that practice. By constructing it this way—rather than just rotating everyone—trust develops between team members, and our providers get to know each other so well. We've conceptualized that we first integrate our outpatient care and then marry our inpatient work with that team, we'll have the full continuum.

Actually, right before COVID-19 hit, we were right in the middle of a complete transformation of our behavioral health care model so patients would have same-day access—it was going to be complete by July. As you know, access is one of the biggest challenges in behavioral health, but we'd identified a way to transform our programs by doing more group work, by taking the waste out of the behavioral health system. I'm hopeful this crisis doesn't derail it.

Lessons in leadership

Q: Roxanna, I'd like to pivot here and ask you about your reflections coming from a senior role at HealthPartners – but not the CEO seat – to the number one spot at WellSpan. Because the difference between being the number two person and the CEO in an organization is worlds apart.

Gapstur: Yes, definitely. I don't know that anything can really prepare you for sitting in this chair. It's like being rocketed off into space. It's just a different view, and you have such a different feeling about expectations, performance and the commitment you've made. I'm learning every day—learning from people like you, and from my fellow CEOs, and from my own team. It's a really awesome responsibility. But I have to say, I've also never had more fun.

You know, I've had a very unusual career. I've gotten to experience so many things that I don't think others get to experience. I was one of the first nurses to work in the HIV epidemic in the early 1980s, back when we didn't know if we could get HIV by touching. (In fact, when I think about this pandemic, it's like, ""Wow, I already kind of experienced one of these.”) I was also one of the first people to open a freestanding cancer center, the very first one in Minnesota. I was also the very first director of the CyberKnife Center at St. Joseph's Hospital at Healtheast Care Center—the first in Minnesota. And I was the first person to develop one of the urgency center models we brought to Minnesota from Texas.

I was thinking about all these firsts, I realize I've had a lot of them. But the first time as CEO is a first like no other.

Q: That is fantastic, Roxanna. A series of firsts. And perhaps even more so because I think there's a stark difference between leadership in ""peacetime"" versus ""wartime""—because I do think COVID-19 is a war. Taking the number-one job in a comparatively peaceful time is complex enough, but then, 15 months into this, there's this unprecedented thing foisted on you. What are some of your learnings here?

Gapstur: I think the wartime environment definitely ups the stakes in terms of how you approach your day. Even at the most granular level; obviously most of us as CEOs want to have great composure, we want to build a great team, we want to motivate our people—all of that.

But then something like this happens and you realize you must over-communicate, you must get deeper into your organization. While we all want to think ahead, you all of a sudden feel the obligation to think, ""Okay, what's two years from now look like, and then let's work backwards.""

I think the increased feeling of pressure, responsibility, accountability is definitely very acute during a crisis; the tough decisions we all have to make get put in far starker terms at a time like this—when we can look back with 2020 hindsight, how do you want to be remembered during this crisis? 

Q: And what have you learned about yourself as a leader during the crisis compared with your leadership during peacetime?

Gapstur: I've always been grateful that I grew up in the Midwest on a farm—I had an upbringing in hard work, which has come in handy because we're all working seven days a week, and I inherited a salt-of-the-earth, pragmatic perspective that enables me to be calm during most of this.

It's made me adaptable—on a farm, when you're bringing in the harvest, you don't get any downtime for about three months, so I've learned how to de-stress while continuing to work, even if that's just grabbing 10 or 15 minutes. That's a great skill to have, because I know some folks become much more stressed during times like this because they feel they don't get any downtime.

Where I haven't been as good is working on not being so hard on myself, right? During times like this, any uncertainties you have about yourself or your leadership only become magnified. I've had to be diligent with my self-talk, thinking, ""Let's look at this objectively. How does this really look from someone else's position?""

Q: I smiled when you said you grew up on a farm, because a couple years ago, when I did a retrospective on the first 50 of these CEO conversations, I realized that we have a very high percentage of CEOs who grew up on a farm—in fact, there were more health system CEOs who grew up on a farm than graduated from Ivy League colleges.

Gapstur: That's fascinating! My grandfather had 13 brothers, and they all built different farms. I had cousins who had a dairy farm, and we had a beef farm—it was certainly a family tradition.

Wrapping up

Q: Now, before we wrap up our interview, I have to ask about your reading list, because I know you're a fanatical reader—you read about four or five books at a time. Can you share what‘s on your nightstand right now?

Gapstur: Sadly, I haven't had any time to read the last few weeks, but I'm a very eclectic reader. I like historical fiction a lot, and I got into sci-fi last year. I'm reading some nonfiction too.

I have about nine books sitting on my bedside stand—in my work reading list, I'm reading or recently finished Hemant Taneja and Kevin Maney's Unscaled and Simon Sinek's The Infinite Game. My non-work reading list includes Hilary Mantel's The Mirror and The Light, Emily Bronte's Wuthering Heights, Neal Stephenson's Fall, and Michael Christie's Greenwood.

Q: I have one final question to ask: As you reflect on your career, what are you most grateful for?

Gapstur: I am most grateful for the opportunity I've had to work with incredibly talented, passionate people. And I'm so grateful for the wide variety of things I've had the opportunity to do. When I went to nursing school, I never thought my career would turn out this way—and now I look back on 30 years, and I think, ""I've had the opportunity to do so many amazing things, and work with so many amazing people."" That's what I'm grateful for.

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Check out Eric's recent must-read interviews with top hospital and health system leaders:

From Ascension to Intermountain and now 'home' at SSM Health: How Laura Kaiser is 'systematizing' mission-based care

Laura Kaiser, president and CEO of SSM Health, talks about the call to nonprofit health care, SSM Health's legacy of caring for ""Our Dear Lords, and why she's completed at least one triathlon almost every year—for the last 36 years.

Marc Harrison promised to turn Intermountain into a 'Tesla.' He wasn't kidding.

Marc Harrison, president and CEO of Intermountain Healthcare, talks about Intermountain's recently announced strategic reorganization, previews the launch of a "virtual hospital" to better serve rural communities, and shares the surprising worry that keeps him up at night. Read our interview with Marc.

'A little bit of a pirate': How Kelby Krabbenhoft built a $6B system—and where he's taking Sanford next

Kelby Krabbenhoft, president and CEO of Sanford Health, talks about the unprecedented CEO-philanthropist partnership behind Sanford's rapid growth, why a successful leader needs to be "a little bit of a pirate", and the merger that will make Sanford a nearly $6 billion health system. Read our interview with Kelby.







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