Interview: Sally Larwood, RN (Part 2) – Jumping Off the Cliff, Together

In Part 1 of our conversation with Sally Larwood, RN, the Chief Nursing Officer at Crossover, we discussed her background in healthcare and nursing, and the challenging, yet rich professional and life experiences that have helped define her outlook on healthcare, work, and family since. In Part 2, we learn more about her return to healthcare and how she came to be at Crossover Health. Stay tuned for Part 3. 

What pulled you back into nursing after ten years?

In 2003 or 2004, my husband’s printing business started to fail. It was a painful time for him; he had to lay people off, some of whom were also third generation workers in the family business. We had a huge house in Atherton, and I can still remember the day he came home to tell our family we would have to move. At the time, I had four little children and two naughty dogs, and I was used to living on an acre of property. We loved the school district we were in, so I said, “Okay, I got this, but we’ve got to keep the kids in their current schools.” Finding a rental in the area and making that move was a hard thing to do, but I also saw it as an opportunity to go back to work, which I had been missing while raising the kids. 

That said, I had been out of the game for about 10 years. I was nervous about going back to a hospital as I had heard staffing models had changed and money was a big thing in hospitals, which was neither what motivated me, nor was it how I wanted to work. So I looked at a different approach. Three of my four children are girls, I didn’t know a lot about women’s health, and I had been losing some of my Spanish, so I applied for a job at Planned Parenthood which served a largely hispanic population. I was totally naive about the politics that surrounded Planned Parenthood, and maybe I should have been more aware, but I was truly just interested in taking care of patients. I was also really focused on learning about women’s health, and the Planned Parenthood clinic I ended up working in also had a focus on primary care, which is an offering that a lot of people don’t know about. 

I had to learn really quickly. When I left nursing, there were no electronic medical records and I came back to a world where EMRs were required for the role. I took it all in stride, did some remedial work, and quickly caught on. Before long, I was deep into Planned Parenthood’s mission, had my own panel of patients, did quite a bit of counseling as well as high school outreach, and learned a lot about comprehensive primary care across the ages, genders, cultures, and socioeconomic spectrums. I ended up teaching throughout California—I’d go to several different Planned Parenthood locations that also offered primary care for educational and training sessions, as the staff were mostly medical assistants. The Planned Parenthood model involved a lot of mid-level providers—NPs, PAs, and MAs—which was a lower cost, more profitable approach with great practice opportunities for these emerging disciplines. I had a lot of autonomy in this role and really loved my job.

While I was at Planned Parenthood, a woman named Kate Kellett who was a biller and front office administrator, was recruited away by this new company called Crossover Health. She was excitedly telling me about her new job as a “Host,” about this new clinic at Apple, and something about some surfer dudes and a new startup. I just remember she was super excited and kept telling me, “They really need a nurse.” I brushed her excitement off and figured she was just excited about the new role, and let her know, “Oh no, no, I love what I’m doing.” And I did. I loved the PP mission, there was a line out the door, I was so settled in, and it worked with my family situation, but Kate insisted, “You’ve got to just at least talk to them.” 

After a couple of weeks of this, I finally gave in, if for no other reason then just to appease Kate. Crossover had no offices at the time, so I met Sarah Shin, our original Human Resources leader, at a Peet’s Coffee near the Apple campus, and she offered me a job within five minutes. I didn’t even know what corporate medicine looked like, but I was intrigued. I talked to some of the founders, I got very excited, and I was comfortable if I left, I wouldn’t be leaving my team in a lurch—at Planned Parenthood, there’s always another health provider advocate who is ready to fill in because it’s such a great place to learn and build your career. It’s also hard to work for many, many years without resources and I had to be honest with myself—I was already thinking about my next move and I knew it wouldn’t be returning to the hospital. Little did I know what I was getting into!

What were your early days like at Crossover Health?

When Sarah was recruiting me, all the talk was about helping open the new Apple clinic. As it turned out, it was delayed due to some facility issues, but there was another equally exciting opportunity at the new Facebook onsite clinic that Crossover had just been awarded. Sarah had me come to Facebook for another meeting, which I thought was going to be like the meeting I had at Peet’s, but it was actually to meet the client. I turned up still in scrubs which was so not the Facebook vibe, and was told I was being hired to be the nurse at Facebook!

Facebook was pretty new at the time. I had children who were wasting so much time on it, so I blurted out in the meeting “I don’t even use Facebook!” I told them I’d love to work there, but that I wasn’t very tech savvy, and that I wasn’t ever going to have a Facebook page. Really! Thank goodness the client saw past that, and I got the job. In my first week, I repeated that I’d work really hard but would never have a page. Within 10 days they created a Facebook page for me. They told me that this is how they communicate. “People are going to see you in the cafeteria, and this is how they’ll want to send you a message—on Facebook.” So I ended up having one, although other people helped me manage it.

We hired a practice manager, who was there helping me set up, but for a number of reasons, she left right before we opened. So our small team had a meeting, and we asked, “Can we launch without a practice manager?” and our answer was, “Yup, let’s go.” It was only me, a LVN, a host, a doctor, and a chiro, and we were completely overwhelmed. Rich Patragnoni, MD said this would be a controlled “soft launch” and we were probably only going to see about eight patients the first day anyway. But we opened to overwhelming interest, had 800 people come to our open house, and saw 40 patients on the first day. We thought we’d be out of there by 5:30, but it was well past 8pm each night that we dragged ourselves out of there thinking that a train had hit us. We were whiteboarding to try and figure out what we could do to manage the onslaught of patients. Rich was seeing patients, which wasn’t in the plan, and I was seeing people in the break room—even in the fire escape.

Since we didn’t have a practice manager, who in my mind is the glue, I started to order supplies and do the time cards, remember that it’s somebody’s birthday, and of course, continued to hire people like crazy. I was the front office staff as well, because we had to let a host go who was overwhelmed by the volume and ended up not projecting that special XO Magic that all the members quickly came to expect. Rich said we had to keep her, but I said, “Nope. Let’s jump off the cliff together.” He and I worked closely together to make everything work that first year. 

That was my entrée into Crossover. It was a wild ride because we had no policies and procedures, no marketing, and no clinical ops to help open clinics or deal with training. Everybody had to do everything. The night before we opened at Facebook, we ran around and left t-shirts on everyone’s desk inviting them to our opening party, not sure if anyone was going to show up. Ha!

Today when people tell me they don’t have bandwidth to do something, I’m reminded that we did everything with no resources and nothing in place. I remember saying to Nate and Scott that we didn’t have an ‘Against Medical Advice’ form and wondering where I could get one, and they said “Write one. Right now.” Scott would send me policies and procedures to edit after a twelve-hour day, but we had to do this, as we had to keep the clinic moving, keep the care top notch, and make money if we were going to make this start-up work.

It was so much fun and so exciting—but I often thought at the time that if I hadn’t worked and lived through some chaotic times (raising four children including one with special needs, handling the switch in homes, working with the under-resourcing at Planned Parenthood, etc.) I wouldn’t have been able to thrive in this start-up environment, nor would I have the confidence—or the stamina—to keep plowing through the chaos. But, because we all chose to jump together, we knew we had to figure it out together as well. 

One of our core values at Crossover Health is “Be Fearless.” Scott always tells me that we have to walk up to the “thin line” that separates fearless from reckless. Looking back, I see that I now understand so much more what he meant. I had personally experienced it in my past, and am living it now. And I certainly try to talk to all of our new leaders and team members about what that means today. There are a lot of newer people at Crossover who are so cautious and careful about how we operate today, but that is not at all how Crossover started. It makes sense now, but we didn’t have that luxury back then. 

How has your management approach evolved with the Company over the years?

Coming from an environment like a hospital or Planned Parenthood, there never was any client to work with. So client management was very new to me, and I plunged into that role. We also didn’t have account managers at the time, so the medical director at Facebook, Amit Batra MD, and I were brought to many client meetings. The founders were still around, but they were trying to hand things over so they could move to the next thing. I had to learn what it was like to be a guest in someone else’s house, and learn to remind them politely that we were the medical experts and that there was a corporate practice of medicine, and gently push back.

After about a year and a half at Facebook, I moved to Apple. I was really excited. It was a much bigger project, but they were a very demanding client. I had to learn, and teach people that we are guests and while we can push back respectfully, there is an art to smiling, taking the feedback, and—Rich taught me a lot of this—that it’s important to not overshare, not push back in a meeting, but simply take the advice and carry on. We were criticized once by an employee for having hosts who smiled too much, which I’m not going to tell them not to do, and we had to understand the culture of engineers who might have felt uncomfortable with gregarious people. I’ve taught practice and account managers to just stay quiet, take the feedback, leave the room and then, after a week or so of careful consideration, respond by asking to challenge or compromise on an issue.

How did you transition to a company-wide role?

I stayed at Apple for about four years. In that time, we opened six clinics—two international, the main clinic at the Cupertino campus, one in Sacramento, and two in Austin. As time moved on and our relationship with Apple evolved, I helped with the transition at the Cupertino headquarters and had to decide who in that team would stay with us, as we didn’t have enough positions for them at the time. It was a difficult time for all of us to lose so many team members and close personal friends that I had led as that clinic became part of Apple Wellness research efforts. 

When I left that role, Scott was very complementary of the work I had done in supporting multiple practices and asked if I thought I could do the same for the entire company. I was honored and accepted the role of Vice President of Practice Management. I stayed at Apple in the interim as we didn’t have a succession plan, but I was supporting all of the practices at that point, and had been really involved in the hiring and training of the individual care teams, nearly all of our clinics, and in the design and launch of each as well. I spent a lot of time on the east coast, launching 30 Rock in Midtown Manhattan, as an example. The only clinic I haven’t been directly involved with is our Las Colinas location in Dallas, and that’s because we now have that next layer of leadership. As Scott has said, I can’t be everywhere or do everything, and so like him, I’ve been learning to let others do the work, and the strong regional team did a great job in Las Colinas. Stephen EO [Stephen Ezeji-Okoye, Crossover’s Chief Medical Officer) and I are taking a regional approach to building strong leadership in the Central, East, and West regions, so we can step back and work on other things.

I spent a good part of the last several years opening clinics and putting teams together. It was a great run, and a great experience, but I accepted the role of Chief Nursing Officer on May 1st of this year. Scott has asked me to focus on Practice Operations, Care Management, and ensuring we launch our national virtual care program effectively. Getting all the leadership and structures in place for these efforts is a huge undertaking. Even more challenging, we are doing this in the setting of “ruthless prioritization,” a global pandemic, a cultural crisis, and an economic meltdown. I have realized that for me to be successful in this new role and during this unusual year, I am going to have to step back and trust that the leaders I have trained and worked with are ready to give more, do more, and be more.  

For example, Joe Ennesser (Crossover VP Operations)—it used to be just him putting together the clinics, but now it’s his team and those he has trained that need to be ready to do this. The teams have grown and there’s so much more structure. To be honest, it’s still hard for me to step back given my natural reflexes—plus I have eight years of muscle memory that is all about putting out the last fire. But so much of my role is also what I really love doing—it’s all of the efforts around people that is where I find my energy. The team out east still calls me in when they have concerns or need an extra vote, so I’m still actively involved in interviewing while at the same time finding I can also be comfortable in this more supportive role. 

Crossover has an interesting approach to clinic leadership—you practice in a Dyad structure. Can you explain what this means and how this works? 

Dyad Leadership basically means partnering, and the way we set it up in the clinics involves a practice manager and a physician manager, generally a nurse and a doctor, overseeing an individual clinic, a market, or an entire region of clinics. We’ve set it up as dyads because as we reviewed all the various leadership models we didn’t see that clinics led by a physician-only or a nurse-only really worked that well. Everyone understands the need for an “office manager” but we wanted to be sure to have “clinical leadership” merged in as well. 

Personally, I was in a dyad partnership with Rich at the beginning, then Scott, who filled in as we didn’t have a Chief Medical Officer when Rich was moving more into product. I set up dyads across the whole country in my old role, and now I’m in a dyad relationship with Stephen EO. It’s structured similarly but ends up different from site to site, based on the personality, profiles, and practicalities of the partners. Often when we hire a new practice manager, they want a list of 10 things they should do and 10 things their dyad partner should do. It’s hard for me to create that list because every partnership turns out to be a little bit different. The relationships should evolve organically, so it’s challenging to make a list before we know the strengths and weaknesses of each partner and who’s good at what.

In our dyad relationships, it has seemed more natural for our nurses to step forward into a leadership role. While our physicians lead out clinically, they are not always as comfortable or experienced in leading out managerially. It feels like they spend so much time in the books and the science of medicine, that they haven’t had much opportunity to focus on the art of managing people and leading teams.  They’re not necessarily as nurturing, they don’t like to have difficult conversations, and they don’t always go at managerial challenges head on. I think the nurses usually come at this a bit differently due to backgrounds and training. We have seen great strides forward by both our MD and RN leaders because we can acknowledge some of these differences, celebrate various strengths, and when done right, bring the best of both approaches to the leadership of the clinic. What I see is that it just takes some time, experience, and a bit of fearlessness to dive into difficult situations, have the hard conversation, and learn to lead just like you learn to manage a clinical case. In medicine, you’re not allowed to make mistakes, for good reasons. You have to get it right 100% of the time, so it’s much harder for physicians to be fearless and try things that are new, different, or out of their comfort zone. This is something that has fascinated me, putting these relationships together and seeing how the nurses and the physicians learn to work together in this structure. Physicians are very bright, highly-educated people, and they’re not used to being told how to do things, so it means a tricky dance that our nurse practice managers have to learn to do. While it takes a bit more effort to get it right, when the dyad partners click and they lead the clinic as partners, this is when magic can happen!

In our final Part 3 interview, Sally speaks about some of the big pivots the company has made including the evolution to a Digital First offering, the impact of COVID-19, and her excitement about the future of Crossover.