Rural Health Leadership, with Steve Simonin

Organizations and resources mentioned in this episode:

• Iowa Specialty Hospital and Clinics
• Critical Access Hospitals
• Rural Emergency Hospitals

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today I'm speaking to Steve Simonin, President and CEO of Iowa Specialty Hospital and Clinics. Thank you for joining us, Steve.

Steve Simonin: Thank you very much.

Andrew Nelson: To start off here, can you tell us a little bit about your background and what inspired you to choose a career in rural healthcare?

Steve Simonin: I've been at my hospital now, it's over 27 years, but it's going on 28 years as president and CEO. When I came here, it was a small little hospital. Before that, I had a couple hospitals up in South Dakota. Before that, I was in New Hampshire at a for-profit out there. Before that, I was getting my grad degree down at the University of Iowa in hospital administration, and my master's. And how did I decide to get into healthcare? I think if you look at the economy back in 1987, there weren't a lot of jobs out there, so I was calling up anybody I knew. I said, “What should I do?” I had a degree in finance, and I didn't really want to work in a bank.

And they said, “Go back for hospital administration.” I'm like, “I don't know what that means.” And I did the two-and-a-half-year program down at the University of Iowa, got an internship with a for-profit hospital out in New Hampshire, went out there in my mid-twenties. I didn't really like the for-profit side of healthcare. I moved back and started running some rural hospitals up in South Dakota at the tender age of 28. I tell people I couldn't even tie my shoes at the time. I don't know what I was doing running a hospital. But it all worked out. After three years there, I came over to Clarion, Iowa, and just started building over here. I started working with another hospital in 2007, and that's kind of where the system started.

So, right now, I guess I'm president and CEO of, I guess we're classified as a system by the American Hospital Association; a couple hospitals and 11 outside clinics, all throughout central Iowa. But you know, it's just organically grown so much in the last 27 years, but in 27 years, it should grow. The interesting thing, when I came into healthcare back in the 1990s, you know, healthcare was completely different. Moms were staying in the hospital for a week when they had a baby.

Now they're basically going out within the same day or the next day. When we started doing lots of orthopedic procedures, you were on a lot of different machines, and you'd stay three to five days. Now, you know, 90-year-olds are going home in the same day, which is crazy. One of the things that I've learned over the years, I think through a lot of personal experiences along the way — my parents both passed away. I came from a very financially-focused administrative perspective, with my for-profit background, with my degree in finance, with the MBA, and through my parents' healthcare challenges, I learned that healthcare is a lot more than just the numbers.

And it happened about midway through my experience. I started in about 1990 in healthcare administration. About 2002 is when my mom passed away, and then my dad passed away in 2008, and they were in hospice. And they used all aspects of healthcare, and I just really learned a lot of empathy, and it's about treating the patients; every single patient that we see more as a family member as opposed to a number. And just changed my perspective. I'm just kind of a late comer to the whole “Ted Lasso”… it's a TV show. And it talks about a lot of empathy, and it talks about a lot of caring. As I've grown in my job, I started to understand just a whole different perspective on how to deliver leadership.

Andrew Nelson: As you mentioned, you're going on 28 years in this field. And we know that strategies and approaches to healthcare that are well suited to an urban environment might not work as well in rural, or vice versa. In your experience, what are some of the similarities and differences between those two worlds?

Steve Simonin: When I was in class back in 1990, I don't remember a lot of classes on, you need to work the community garden or go to the shop in the local town or buy a car here or do a lot of those things that are unique to a rural community. It's about relationships. It's about knowing the people in the grocery stores and sitting next to the people at the baseball games. And we used to follow this guy by the name of Quint Studer, and we still do, Quint's a friend. And, Quint said, “You know, Steve, the difference between a rural and an urban environment, if I fire someone in an urban hospital, I'll never see him again. You'll be sitting by him next to him at church next week, or they'll be my neighbor. Or they'll be in the grocery store, so you have to go about things differently because you're going to be living with these people and you're going to be taking care of them.” And so, when friends and neighbors and community members are in the hospital, and someone will say, “Oh, Mr. Johnson's in room 5 from your church.” And it's different. I've got two small hospitals of 22 and 25 beds each. And when we have situations that happen in the ER and the community, and those are my friends and neighbors, it is completely different. It's less management and more personal leadership. During snowstorms, people will be staying over at my house, we'll be out helping with the walks. We'll be serving in the serving line. I didn't sign up for this. This isn't what I thought I was going to college for. But I'm so glad, I'm so thankful that this is the opportunity that I've had to be able to serve.

Andrew Nelson: You're more part of a community in those rural areas.

Steve Simonin: Yeah, I remember one of my bosses, way back when I first started, when I was with the system, said, “Hey, Steve one thing you never do, don't buy a Corvette or a Cadillac or have too showy of whatever, because people are going to notice, you know?” You want to be pulling in the same direction, you want to be part of the team.

When I first came in here 28 years ago, one of the things that I was told, I met my CFO the first day, Darcy, and I said, “Hey, Darcy, tell me some good news.” She goes, “I've got three pieces of news for you.” And I said, okay. She said, “Well, today's my last day.” And I'm like, well, that's not good. And then she said, “We have no money for payroll.” And I'm like, well, that's not good. And she said, “The employees want to unionize.” I said, “Well, that's really not good. What's going on? It can't be me. It's my first day.” She said, “Administration and the employee team are completely divided, and you need to work on how to bring them together.” So one of the things that we started doing at the time was we started teams, and we started employee satisfaction teams and had them participate in making decisions. We started doing a lot of employee rounding, and figuring out what makes people tick and what makes their life full.

And I've always told the employees: Work should be a priority in your life, but it shouldn't be your number one priority. Your number one priority is your family. It's your community, it's your church, it's your friends. Work should complement your life. You should be able to come to work and find your best friend. You should be able to come to work and laugh. It shouldn't just be the place that you're getting a paycheck. It should bring joy to your life. You're spending a lot of time at work.

Andrew Nelson: So we've talked about the connections you have with your patients that might be your neighbor or that you see in the community and what it's like with the people that you manage. Another piece of the puzzle is collaborating with local stakeholders. That's a crucial part. How do you go about fostering and maintaining relationships with community leaders and government officials and other community stakeholders?

Steve Simonin: I would say one of our main stakeholders are our providers, and a lot of places providers are typically a different group; a lot of times they're not employed by the hospital. And back in 2002, I remember talking with one of my docs and he said, “Steve, we want to be employed by the hospital.” I was part of the same network. And I said, “I don't think the network wants that. I think they want you to be separate.” And they said, “Well, then we're all leaving the hospital.” I'm like, “So I'm going to have to close the hospital.” They said, “Yep.” And I said, “Well, we'll figure out how to hire you.” So we hired them; I got fired for that.

And I was hired by the hospital same day, it was not a big deal. So we're all very independent. And I said that the providers, the staff, again, we're all pulling in the same direction. We're going to go down this path together and it's going to be one big team, and it's not a competition. Same thing with the community. One of the interesting things about rural hospitals is that a lot of times they're taken for granted in a small community. And most of the time we're the leading employer. And we bring a lot of people to the community. And so it's imperative, if we're going to be successful, that we need to work with the downtown businesses.

You know, we need to be their providers. We need to do as much business as we possibly can in the community and partner with them. It doesn't serve our purpose as a local community hospital. Even if we are doing a lot of specialty services, if we don't have good relations in our community, you know, then we've missed out. We all need to be one and the same. Again, it's like complimenting the employees on their job. We need to be the center of economic responsibilities. So, with that, we try and have as many of our leaders and staff in the chamber. We try and be involved in economic development. We, you know, we sponsor a lot of the local teams and participate in the sand volleyball things. We really push local consumerism, shopping local, the whole bit.

Andrew Nelson: One of the struggles that you see in rural healthcare a lot is workforce shortages. What kind of strategies have you implemented to try to not only attract, but retain skilled healthcare professionals?

Steve Simonin: We talk about COVID a lot, obviously, you know, it was a huge factor in the world and especially with healthcare. The interesting [thing] about north central Iowa is one of my county's big things was, we produce all the eggs for McDonald's west of the Mississippi. So we have a lot of chickens, we have a lot of pork, we have a lot of flat land. We have a lot of corn and soybeans. So we don't have a lot of things that people would want to move to town for. So when we're looking for talent, they're like, “What do you guys have?” You know, we have great jobs.

When COVID hit, what we found was a lot of our staff were going for the high-paying agency jobs. So, like a lot of staff and a lot of hospitals, we started to see that we were losing staff and they were going elsewhere. So, we've always been on the struggle bus to bring back the employees. Same thing with docs; I remember one of my orthopedic docs. He's fantastic, and he was lead resident up at the Mayo and just a fantastic orthopedic guy and worked with the Olympic teams and the whole thing. And I talked to his mom, and she said, “He's not coming back.” I said “Yeah, he will.”

And so, we needed to present a situation where he'd want to come back. And that's the thing, we need to look at our communities in the grade schools and the junior highs and the high schools and start recruiting at that point and saying, “You guys, you know the community. This is where you want to come back to. We want to be the provider that you want to come back to. What are you looking for?” So, I've got a bunch of docs right now in school and residency and getting ready and we're asking them, “What are you looking for?” And a lot of it is flexibility, and a lot of it, pay, absolutely. We have to be 100% with pay, or better than others.

But it's flexibility and their ability to practice medicine in an evidence-based way or with great colleagues, so it's building that foundation of incredible partners and colleagues and in an environment that trusts them. I used to tell the docs, I don't say this anymore, but I said, “I don't have many talents. I can play a mean guitar and I can make a great omelet, but I don't produce the revenue. You guys do that. I'm an agent for you guys. It's my job to give you guys the best practice you can possibly have.” And that's what we do.

So, best place for employees to work, fantastic engagement. Meet them where they need to be, or they want to be providers. Give them the best practice possible. Give them all the tools and equipment they need to do their own job. And, you know, if they want to work halftime, if they want to work three-quarter time, you know, figure it out, Steve. That's the challenge that we have. And it works. People see that we respect them and their lives, and they pay it back.

Andrew Nelson: You just talked about some of your experiences with staffing during the pandemic. I'm sure leadership in healthcare requires a huge amount of adaptability, especially when you're dealing with unforeseen challenges like a public health crisis. How have you gone about preparing your organization for… how do you prepare for the unexpected? Yeah. And what are some lessons you've learned from past experiences you've had?

Steve Simonin: You know, I was vacationing down in Texas when, when COVID hit. And I got back up here and the whole hospital had changed. This was before mandatory time out if you had been traveling. And I said, “I'll be the first one, I'll jump at home.” So, I started doing videos from home, and I started talking to the staff. We set up a lot of things like telehealth.

We started a closed Facebook group where we were talking to employees on a daily basis. Because a lot of them were at home. And we just started having goofy messages and talking to people, and how do you prepare? How do you prepare for pandemics? You don't prepare for pandemics because nobody knows it's coming. But what you do is you have an environment where it's easy to be fluid, and it's easy to pivot when necessary. And I remember back in 2006 when we kind of accidentally took on five orthopedic surgeons, and we weren't necessarily ready for it. And we said “Yes,” because I thought they were doing negotiation, and they're actually serious. We had a very strong organizational, excellent culture going on, and we were able to pivot, and we were able to change what we needed to change in a very short period of time.

So I think that's it. I think it's being prepared for the unexpected and the undefined, and that's a hard place to be. But I think that if people aren't so set in their ways and solid on their direction and expect change, expect fluidity, expect to be able to pivot, when necessary, it shouldn't be a surprise. And changes are always coming. One of our specialties, I have a specialty hospital, is we have a strong bariatric program, and we do a lot of bariatric surgery, and a lot of our patients are coming from 90 miles away to have bariatric surgery up here. And one of the things that's really been strong on, and you see commercials all the time for, are the weight loss drugs, the Ozempic and the Mounjaros, and it's changing our service a lot.

And we're seeing that healthcare is being changed by new drugs on the horizon, new treatments on the horizon. So we've got to be able to be flexible enough to say: Okay, what's the next thing that's going to be coming along, and just being open and aware to the environment. And the interesting thing is, Iowa gets things a while after it's already been tested on the coast and big cities and things like that. So, one of the things that we need to do is we need to be aware of what's going on, whether it's in New York or California or Chicago or whatever and know that that's probably going to come to Iowa in a year or so. We need to be prepared for that. And we need to start educating ourselves and start looking at the trends and start looking at what's going to be happening.

Andrew Nelson: What are some considerations that are on your radar as we look to the future to ensure that rural healthcare can continue to be sustainable and financially viable?

Steve Simonin: The Critical Access act was passed in the Balanced Budget Act in 1997. And I was new to Iowa. I came here in '96. And so I got onto the committee because I was working with a cost-based test hospital up in South Dakota. And so they put me on a committee to bring Critical Access to Iowa. In 2000, Clarion was one of the first hospitals in Iowa, one of three, Belmont, my other hospital, was another one, to go Critical Access. Just a little bit about Critical Access, it gives cost reimbursement, it gives a different reimbursement for rural hospitals when compared to urban hospitals. There's a lot of beneficial things out there for rural hospitals, but as you're seeing as the changes in medicine are coming, there's less and less of a need for hospitals and acute care.

And so that's a challenge, because we have 118 hospitals in Iowa, and is there going to be a need for 118 hospitals in 10 years? Maybe not. So then what? And that's a question we all have, and who's going to survive and who's going to do well? I don't know, but we need to be aware of potentially what's out there. It's a lot of study and who knows, and Critical Access with new administrations that might go away. Medicare might change how they're paying people. Medicare Advantage might come in, or a new drug might come out that cures all whatever, and all of a sudden, we're not needed as much as we used to be. I don't know. How do you guarantee success? I think just being as aware as possible and taking advantage of situations as they arise. It's scary every day.

Andrew Nelson: It's a lot of responsibility and I'm sure it involves a lot of unknowns.

Steve Simonin: The good thing about healthcare is it's always going to be around, you know? And when we start, what we're trying to do with our leaders and our employees right now is start looking at healthcare, not necessarily as sick care, but wellness care, and how do we take care of ourselves? And one of the new things that we're looking at is we're going to be starting up a longevity clinic. And one of my docs has said that every human can live to be 120. And a lot of the things that we're going to be testing for are early markers on cancer. A lot of this stuff is being done now in Princeton and Cleveland Clinic and a lot of other places throughout the nation.

So how does that fit with rural hospitals, and how do we bring healthcare to our communities from a high end, and then from another end, if we start looking at things like social determinants of health and start saying, “Are we a food desert? Is everybody getting fed appropriately? Does everybody have access to basic resources in the community? And how does the local community hospital get involved in that? And should we have community gardens?” We've had a community garden for the last 20 years. We just give the dirt plots away to people in the community. We water it and we share in the bounty. And those are the things that make a rural community, make a healthcare community, successful. When you're focusing on all of the elements of health, be it food, be it medicine, be it other supplies, et cetera.

Andrew Nelson: Obviously, you have a lot of experience in your position when it comes to the hospitals and the clinics that you oversee. What are some ways you'd recommend that rural health leaders can engage at state and national levels to make sure their concerns are being heard?

Steve Simonin: We just got done with talking with one of our speakers for our leadership. And we were talking about our mission and vision, and one of our vision statements talks about being an example. We have a really robust OB department. We delivered around 600 babies this last year, which is unheard of in a rural community. And so we're getting a lot of attention from our state and federal saying, “What are you guys doing differently?” And a lot of times what we're doing differently when we have extremely successful services, other small hospitals around us are closing their OB units, and we're getting a lot of those patients coming up here, but how do we say to our state and federal officials that this is what we need to do is, pointing to quality and working with our local legislators and letting them know of the issues that we're going through.

And that if we are having issues with regards to bringing employees in, bringing nurses in, how easy is it, for example, to get international nurses? I know that a lot of nurses come over from the Philippines, so how easy is the visa process or the green card process? Same thing with J1 visa docs, and we've got a lot of undocumented people in our community right now. Because they don't have the proper documentation, they can't work at the hospital, but there's a lot of need; how can we marry these together? And then just working with the legislators to say, “This is red tape that we need to have worked through.” And they're very aware of issues within the communities, and they want to help us. They just need to hear from us. So we just need to communicate. It's about basic communication, saying, “These are our needs, you can help us.”

One of the cool things is, here in Iowa we worked a lot with Senator Grassley. And so we have this new thing up for rural hospitals called the Rural Emergency Hospital. And it's the next step forward as far as how we can continue to provide services. And Senator Grassley worked a lot with the state of Iowa and small hospitals, listened a lot, and was able to get this through. And it was like when Critical Access went through in 1997, it was a lifesaver and a life changer for a lot of rural communities who were on the brink of potentially losing their healthcare. So it's working — thank God for senators who really listened to the constituents, because this is exactly what we needed.

I think one of the things that has always made us successful is just developing relationships and making sure that we know everybody from our legislators to our employees, to the people in the community, and it's about communication. Good communication is the secret to life, you know? And so it is about being around and being present and being aware and conscious.