This interview with Knox Singleton, president and CEO of Inova Health System, was conducted by Eric Larsen, Advisory Board managing partner, and condensed by Dan Diamond, executive editor.
Q: You're marking a great milestone—your 30th year as the head of Inova Health System. You're one of the nation's longest tenured system executives; what's surprised you about your career?
Singleton: Historically, we tend to think of our careers as having an upward slope. As you progress, things get better and you do more impactful things if you're perpetually challenged as you move up.
But I look back 30 years, and it's more of a U-shaped experience. When I became CEO at Inova, I was 35 and didn't have much of a clue. That I was far too young and inexperienced to know what I was doing.
Though you know, Churchill said nothing is so [exhilarating] as to be shot at without result. The whole notion is that you're in a vulnerable position … the gap between what you're asked to do and what you actually know how to do is a very bracing time.
But that makes for a lot of fun. I always say that your learning is inversely related to the amount of challenges in your role.
The only time you really learn is when you try and do something you don't know how to do.
Q: So that explains the steep curve at the start of your career. How has the 'U-shape' manifested for you in recent years?
Singleton: The environment wasn't changing very fast in the 1980s and 1990s. But in the last 10 years, [health care] has changed so much—having to learn the whole managed care business and medical group management and a variety of taxable enterprises.
So there are new environmental challenges for leaders, and with those changes means there is more opportunity.
You know, I think now is the best time to have been in the health care business in my 30 years.
Q: But not everyone is able to respond to those challenges.
Singleton: I'll use a military analogy—there are more battlefield promotions. There are rewards for people who are good at what they do. Before, poor performers were tolerated; now, people who are not so strong get [taken off the field] and it creates a lot of opportunity.
I think an enterprise today is much more likely to fail if it doesn't get good leadership. That's more bracing but it creates a lot more new places to go.
I really credit health care reform for creating the best environment in health care. What I mean is that even if health reform didn't contribute directly to these changes, it was the stimulus for unleashing a lot of pent-up change.
Q: I couldn't agree with you more. Whatever homeostasis there was a few years ago, that's out the window now.
Singleton: Exactly. People got over the cultural hump of "do we stick with the status quo or do we change?"
And once you get to the point where you have to change, then a CEO really can lead with a lot more gusto. We've been stuck for 50 years in health care basically doing everything pretty much the same way.
Traditionally, when you had 30 years experience in health care, you probably had the same three years experience 10 times over. Not anymore.
Q: In that spirit, what do you know now that you wish you'd known as a young CEO?
Singleton: It falls into two categories. The first is broad: how do you fit together an active professional career with the rest of your life? That's the stuff that Steven Covey [has written about], and things that I learned later on.
The second has to do with what makes you successful. For a long time, health care leadership was really characterized by the idea that success came from your organizational model. What I'd call the strategy side of the equation.
I learned over time that while that was important—and always will be important—the quality of your leadership and execution are even more critical.
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Q: Can you explain what you mean by that?
Singleton: An awful lot of health care management was built around the idea that if you could learn enough about linear optimization or modeling the optimal strategy of health care mix, that was the [80/20] of success.
But I think we're coming to appreciate that the human dynamics are probably the most important part of your leadership, and content knowledge is frankly not all that important.
And the flip side of that has to do with execution. As Larry Bossidy said, execution is strategy. That actually creating a performance-oriented culture isn't about relying just on tools, practices, or strategies.
I remember when DRGs were introduced, and thinking that was a big deal. In retrospect, that change wasn't the part of the equation that was the difference-maker. It was the capacity of the organization to play the game … and a whole set of skills that don't have anything to do with being paid.
TIPS ON COMMUNICATION
Q: As a leader, you have a signature communication style, especially through the Knox blog. How did you develop your voice and what you choose to discuss?
Singleton: Different leaders seek to connect with the folks that they lead in different ways. And I think that you basically have to connect with them where they are. It doesn't matter too much where I am.
The other piece is that you want to add a narrative so that things fit into context. I decided early on that it came down to storytelling about humans and relationships.
Q: Can you give an example of how that fits together?
Singleton: There are only three kinds of relationships in most people's lives. The relationships with their families. The relationships with their pets. The relationships with their friends.
So if I have something I want to tell folks, if I do it in a story about their family or their pets or their friends—well, people can relate to that. Everybody at your organization at some point has lost a beloved pet. I think it's a functional connection for me.
Q: Why adopt such an informal tone?
Singleton: The bigger the organization, the more likely it is that your staff doesn't really know people in leadership. And if you don't find some way to humanize those leaders, they basically become a stereotype that [reflects] the organizational strategy.
If you're a profit-making company, a CEO might be "just about the earnings." If you're a service company or a nonprofit, maybe "you're just about survivability."
But the more you can humanize your leaders, the more that those characteristics get applied to the characteristics of the organization. So your staff knows that you care about people, they know that you try to use good judgment in choosing goals.
They also know that you make mistakes. That means it's ok to talk about safety, it's ok to talk about problems and issues because everybody's got problems and issues.
If your staff think you are in line with their fundamentals, they cut you a break for most of the other stuff.
STRATEGY ON BRANDING
Q: Inova's crafted a very interesting course—you're a community hospital system surrounded by competitors in the Washington, D.C., area that are anchored by AMCs. What's your strategy, especially when considering the future of the community-based hospital system?
Singleton: Our strategy is [largely] driven by health care reform because we think that it's a shorthand descriptor of what's taking place in the market. In the short term, that's the expansion of coverage and the reduction of hospital payments.
My belief, you're going to see a bifurcation of our health care system. There's going to be a very low-margin, high-volume system, and the economics are going to look more like a supermarket or a car manufacturing business.
The other end is going to be high-brand, high-margin, high-amenity access.
It raises the question—what kind of brand do you have to have? And being a community hospital brand is not a desirable brand. The community hospital brand is high-touch, low-tech, low-sophistication. No obvious focus on research or education.
Q: Which is a difficult shift to pull off.
There's the notion that in each industry, the key differentiator is the creative class, the people at the high end. In medicine, it's the clinician investigators who have historically hung out at the academic medical centers.
The true investigators are trying to do basic science and win the Nobel Prize. There's another group of clinician investigators who want to [commercialize] the basic science.
The AMCs basically built their enterprise on the government-sponsored research business. The problem is, that research business is heading into the tank rapidly for a variety of reasons.
So you've got a ton of those human assets that are available. And that's why we are really investing heavily in translational research, investing heavily in medical education [in community medicine].
Our strategy is to build a brand that is driven by what I would call "an academic medical center in application." We try and capture those folks as the research model runs out of gas, and we put them to work actually putting new knowledge into practice.
Q: So how do you get patients to understand that you're shifting gears, while keeping all the positive brand identification you've built for Inova?
Singleton: Take Toyota. The reason they dreamed up the high-end Lexus brand is that it's much easier to put [meaning] into a new name than it is to transform the old one.
Think about the source of our health system's name, too. When I came here, it was to lead the "Fairfax Hospital Association." And when we left Fairfax and Alexandria and Loudoun and all the local identifiers behind to go with "Inova," people said we were crazy—at the time Fairfax Hospital had a great brand.
But that was part of the problem. Fairfax had such geographic identification that you couldn't convince anybody from Alexandria to go there.
It's the same thing now. We're going to have to pour the identity for our premium brand into a new name. The question is, do we brand the low-end product differently and keep the Inova name for a high-end product, or do we leave the Inova name for the low-end product and come up with the Lexus for the high-end product?
Q: Let's bring this conversation full-circle, or at least complete the U-shape. We began by talking about what you learned as a young leader. What do you make of today's young leaders?
Singleton: My assessment is that the Millennial generation is superior in terms of their leadership potential compared to the Gen-X or Boomer generations. Half of them want to go to Harvard Business School, and the other half want to get degrees in Sociology. And so many of them are saying, forget Wall Street, I’m going to make an impact in the world. And they have the risk-friendliness to actually do it.
So I believe a lot of the organizational success is going to be driven by how we bring Millennials into management faster than previous generations. At this stage, largely middle management, but higher levels of management later on.
That has to be intentional. Millennials can have very low organizational attachment and they are "give-get" in terms of their employment deals.
Q: But the Gen-X folks and Boomers can bring something to the table, too.
Singleton: Here's the thing in the last 10 years that I’ve enjoyed the most: when you get to a certain age, you don’t have to know much, but people think you know stuff. So you’re given license to be more engaged with development.
One of my personal hobbies has been cofounding an organization called the Global Good Fund, with a 27 year-old who used to be our Director of Vision Translation. The Global Good Fund targets high-potential young leaders in social enterprise. The kinds of non-profits that have a social mission, but are run as a business.
I really think that mentorship, this idea of taking a Gen-X or a Boomer and pairing them up with a Millennial around purposeful development and coaching, whether it’s inside the health industry—or in social businesses in Bangladesh—I think it's going to help address many of the world’s societal problems.
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