In Part 1 and Part 2 of our conversations with Sally Larwood, RN, Chief Nursing Officer at Crossover, she took us through her background, experiences, and ultimately what led her to Crossover. In this final installment, Sally speaks about leadership, the pandemic response, and the company evolution to a Digital First model.
You’ve spoken about the need for leadership skills. How will you build these?
At Crossover, we’ve always tended to promote from within, which is a great thing, but we’ve not yet had a chance to really measure people’s leadership skills, even when they’ve proven themselves clinically. That’s something we’re changing. There are very few people in healthcare who have had leadership training, and the majority are nurses, not physicians. Stephen EO, our Chief Medical Officer and my Dyad partner, is an exceptional gem because he has such great clinical AND leadership skills. We’d like to clone him all day long, especially as he has such strong EQ as well. Most physicians don’t always have the soft skills of reading people in an organizational setting, and we’re trying to put more thought behind how we develop this with the many leadership programs we have created.
Scott and Rich are unique physicians in how they view a physician relative to the rest of the team. One of the reasons I’ve stayed around here as long as I have is the philosophy of professional equality that has always resonated with me. I still interview and hire a lot of the physicians, and I’m very transparent up front that the “god-like” stuff that’s still around in hospital medicine and the east coast training programs doesn’t fly at Crossover. I don’t want to scare people away, but I did hire a few east coast-trained physicians that thought they’d earned their white coat and their tie, and yet here I was pulling that tie off during the interview! We’re all about an environment of equal opportunity and mutual respect, and have moved away from what we consider to be an unnecessary hierarchy. It often exists, but it is completely opposite of the care team-based approach we take at Crossover. We don’t call anybody ‘doctor’ in our company and I like to set that tone right out of the gate. When the doctor walks in and says, “Hi, I’m Ken…” it makes the patients more comfortable, and sets up a different relationship with the rest of our team members as well. We have also found that this enhances, rather than diminishes, the important role the physician must play to be effective. We have a lot of data and now a decade of evidence to support this approach. I love how this reflects the values of our company, and the founders set the tone—no ego, no power grabs, no throwing titles or objects around…nothing.
Speaking of values, what Crossover values propel you the most?
Definitely “fearless.” I love to be challenged. And I’m clear that I come from a different generation and I’m trying to learn things, but I’m open and honest, so “authentic” resonates deeply with me as well. Even though I’ve been involved in the design of workflows and the clinics themselves, I’ve had to stretch myself to more fully embrace “design everything” so I keep working on it.
Could you describe the growth and transition of the company from your perspective?
One of the biggest changes I’ve seen is us coming out of “startup” mode. We spent a lot of time using our startup stage as an excuse, but in the last couple of years there have been a lot of conversations about the fact that we have to grow up!
At one point, we felt like we were coming across as ‘too nice.’ We liked everyone, tried to help everyone succeed, and as a result we didn’t always make good personnel decisions. Scott’s ohana idea of the Crossover family is hugely popular and important, but sometimes it makes us reluctant to transition out people who do not fit into our future, and we are now at the stage where we have to collectively act like an adult. Celeste Ortiz brought the idea to us that maybe we’re too nice, and suggested we have to make tougher calls sooner than later in an effort to continue to maintain excellence within the organization. We’ve talked about this as the transition from a “Family” to a “Team”-based business. We have to be efficient, we have to be effective, and we have to be cohesive. We are getting better at realizing that Crossover isn’t the right place for everyone to succeed, and it is the right, honorable, and difficult thing to do to have those hard conversations, to guide people out of the organization, and to see them succeed in other environments. We want to see our XO Alumni continue to do well wherever they go.
This shift is really the difference between tolerating cousin Vinny always causing problems for the family, and deciding instead that if Vinny doesn’t perform consistently the expectation is that he will be cut from the team. There are always elements of family in any great team and we will preserve those, but we also have to bring in the harsh reality of competition, profits, and margins.
One of my superpowers is reading people and understanding if they’re going to fit. We can teach the skills but, for instance, if you’re a nurse and expect a big binder of policies and procedures, you’re going to be disappointed. We are not the VA, and we are not a big hospital. And we don’t want to be. Our training is constantly evolving because we’re constantly evolving, and we are acquiring a lot more structure, but we’re never going to be the company with the binder as you walk through the door—which is far too common in medical settings. Instead, we hand you a big blue pen and a small red pen and invite you to get to work on building something great by contributing to the chapters we are still writing.
How has the role of the nurse changed in Crossover, and how should it continue to change?
Building on the Dyad concept, I want the role of the nurse to be much more of a partnership. I want to give nurses a seat at the table. As we’ve moved into population health management, we’ve realized we have not been using nurses as effectively as we could, and we are now creating more service lines and condition based “clinics” for them to run. This reminds me of the autonomy and joy I experienced in creating those hospital-based services so long ago. We want all of our nurses working at the top of their license right now, in so many ways, and I want a much more equal partnership. Stephen EO, Scott, and Rich understand this naturally—they know who’s “really” running the joint—and that is why our nurses rally to work for physician leaders like this. I have been charged with building out this care management approach, and we are piloting these concepts right now with our 30-Day Covid Care concept, travel, PREP, and diabetes clinics. We are also looking into other conditions that would leverage our Care Standards and Care Pathways to form the foundation of a comprehensive condition management program. We have so much more data and access to patient-specific information than we ever have. I can’t wait to see where all of this leads.
It’s funny. We have been saying these things over the past year but in my mind have been a bit slow to make some of these changes more visible to our nurses. When I was at Facebook, Amit Batra, MD was the medical director and at the time, I was referred to as a practice manager. It didn’t bother me for my own sake, but it set up a hierarchy that I didn’t think put our MD/RN Dyad on equal footing. We talked through this as a leadership team and realized that with a small change, we would, could, and should match the MD/RN Dyad equally—manager to manager, director to director, and regional leader to regional leader all the way up. I was one of the first practice directors which set a nice tone and matched me up with my medical director partner. Titles aren’t important to me, but these nurses are working together with the physicians to meet clients and set up processes—and they need the same titles. That makes the intent visible. I love working for a company where nobody even blinks, where they just say, “Oh you’re right. That makes sense. Let’s do that.” I also appreciate that we carried this all the way up as I was promoted—I am now partnered and paired as Chief Nursing Officer with Stephen EO as Chief Medical Officer. I was happy to see this carried all the way through. While a small example, this integrity and ethos runs all the way through the organization, and gives our nurses the fuel to thrive and perform way above expectations.
How has Crossover adapted to the pandemic?
We did an amazing job pivoting to the pandemic. It was unbelievable that on Monday we talked about the move, by Wednesday we were doing it, and by Friday the entire company had transitioned. Literally, that fast. In retrospect, it was so natural to move so quickly and efficiently to virtual visits because as an organization we had been discussing this for about 18 months. It obviously wasn’t as easy as flipping a switch because there were some all-out training efforts to help our care teams learn how to operate in a virtual world. Some of our providers had never used Zoom. We had to provide technology and training for our people, and check them off to make sure they had the right environment to make a video visit, to help keep our experience standards the same. I am really proud of our care teams and how they responded.
Some of our clients have wanted to maintain an onsite clinic so we’re rotating teams and support staff; those were tough decisions, as some team members didn’t want to go into a health clinic or use public transportation. In big cities like San Francisco and New York, we’ve introduced new policies, allowing our own employees to be reimbursed for Lyft and Uber rides on their way into work. There were so many things we had to come up with quickly, like an emergency package for people who didn’t have childcare. We’ve had some of the people, like hosts and acupuncturists who can’t deliver what they do easily in a virtual world, go back and set up training, work on continued education, and contribute to all kinds of other relevant projects that push the care teams forward.
I believe Stephen EO has gone into great lengths about this in your interviews with him (Part 1, Part 2, and Part 3). We set up levels of severity of the pandemic for how we could proceed, what protocols and services we would have in place at each response level, and now have been actively working with clients on how to get Back to Campus. It has been a continual rollercoaster of activity and adjustments.
What’s your view on the potential of the Digital First model? Did you see this as part of a natural or circumstantial evolution of the model?
I think the potential is really, really high based on preliminary feedback we’ve received over the last three months. To be clear, we saw a tremendous spike in usage, but I still think that true adoption will be slower, even though the members tell us their health is less of a priority—even in the pandemic—given all the other social, political, and financial issues. People are trying to figure everything out with their job and their family life, but we are hearing from a lot of companies that remote work is really working for them. We’re talking to some companies that say they’ll only bring 25% of their employees back—ever. Some companies are doing quite well in this virtual world, so I think people will realize that they can have much more of their healthcare delivered digitally as well.
Some of our clients who we serve on campus and at our nearsites are now asking us to help with populations where there is no clinic, and very little chance there ever will be one. This is where our experience with the Sherpaa acquisition has really been helpful. While Rich and Jay ran off (as they should have) to build the new combined product, Scott and I were left running the actual practice. He was interested in understanding how this new model could scale, and I was tasked with gaining a deep understanding of how it actually operated. We had some wonderful physicians who were doing heroic things but the practice still needed to operate, and it required a deep understanding of licenses, call schedules, response times, managing new clients, learning to serve retail members, and thinking through how to expand and grow this model. In hindsight, that study really taught me a lot, and we are putting those learnings directly into practice at Crossover.
For example, we learned that given the crazy patchwork licensing in the US medical system, it is really hard to put together a “practice” that shares calls instead of just doing shift work like most gig telemedicine providers do today. While there are efficiencies in the “gig MD economy,” we see that the relationships need to be managed and fostered, so we take a fundamentally different approach. We have designated care teams for defined populations—you should get your same physician 85-90% of the time in our model because we see that healing relationship as part of the care we provide. We also saw that we needed to regionalize call coverage, and that by doing so, the licensure effort becomes much more manageable as well. Finally, we have gone way down the rabbit hole for all the individual state licensure requirements to ensure that we could create our four regional care teams. It is a shame and a scam how the licensing works in America. Digital technology has just totally outpaced the licensing regulations—it would be funny if it wasn’t so awful and problematic for all of us actually trying to provide care across state lines. But, with this new utility in play, we are going to be able to truly “switch on” populations.
How do you transition people to a digital channel so they feel that they might actually be getting something equivalent or even better that traditional care?
The Sherpaa experience that I just described was really helpful for me, and I saw how happy people were with this style of care. I’m now in full sell mode, pushing the advantages to providers who are still concerned about this new model. There’s hesitation from some of our providers to deliver purely asynchronous care. They find it hard to wrap their minds around what that looks like. This will be one of the things that we not only need to show to our providers, but also to our clients and members to help them understand it as well. In my mind, this will be just like our nearsite concept—we will have to show people how it works and then it will be understood.
One of the things I tell physicians is that today, they’re in with a patient for 30 minutes and they shouldn’t be expected to know everything. I explain what a luxury it is to be able to message with a patient, and then go engage with a colleague or refresh on a topic, look up the latest research, and then come back to the member with multiple, thoughtful options to consider. And because there’s no daily schedule, when you have a few episodes of care come in your queue, you’re able to self-triage to determine what can wait, what needs follow up, and what should be dealt with right away. It’s that time dilation we have talked about in some of our meetings. When you’re seeing patients in person, you don’t have that same luxury—if your 9 o’clock requires more attention, and your 10 o’clock is minor, and you go over, it’s a challenge. In digital, that 10 o’clock will be just as happy with a quick message. We are also seeing the value of care navigation and emerging roles for the nurses as well. In fact, we coined a new term that we call “care traffic control” for the nurse who engages with every member and provider at the practice to ensure all the trains run on time. This is the classic charge nurse, now retooled for the digital world. We’re building on that by making sure our nurses are licensed in all the states that our physicians are, and these nurses can help start the episode in a way that ensures the patient feels their needs are being met. This role and these concepts are new to some of our providers, and we are making adjustments and changes as we learn to work in this new way and in this new world.
We have always loved the concept of team huddles and out of necessity we’ve been doing these virtually for the last couple of months. In fact, various members of our leadership team are up at 5AM several times a month on phone calls with our teams scattered across all the different time zones. I want the virtual teams to practice in that same way, and to be connected deeply into XO and into each other as care providers. We’ve built beautiful virtual centers at North First (San Jose, CA), Las Colinas (Dallas, TX), and Manhattan (New York, NY) for instance, because our concept is that the virtual teams should be together physically—it is just the patient who will be virtual. Because of that, we had to pass on a lot of providers who were experienced with digital and asynchronous care because they didn’t want to be part of a regular team. We have modified our thinking since the pandemic, and are now not requiring the physician presence, but still have the same team-based practice expectations. So our virtual huddles and team meetings have become doubly important.
This has also spilled over into how we train nowadays as well—we held 100% virtual training for our first Florida-based team. It was a bit clunky, but we’ll get better and better at it. People found it hard to believe that we could provide quality training virtually, but we’re doing it, and we’re going to keep improving as we go forward in this new world.
And of course, the other part of going Digital First, is it is going to allow us to really scale our model. Look at behavioral health, which is really big in places like NY and SF. We can move away from the 30- or 60-minute visit, and instead start the back and forth in our platforms, gather a detailed history, initiate some basic therapy, and then followup in person as needed for the most acute. What I love about this messaging is that the “communications become the documentation.” Both providers and members, particularly when they are connected in an ongoing relationship, can look back and see who they’ve worked through something with, remember what was said, and how to best follow up. It is by far a more organic and natural way of communicating and addressing the various issues as they come up.
What’s your favorite memory of Crossover?
My favorite memories will always be the times around Crossover opening clinics. I have had the experience of being a mother of teenagers who actively participated in theatre at school, and every opening of a clinic reminds me of that. I still think of the night before opening a clinic as the night before opening a new play at the theater. There’s this very real experience of going through ‘hell week’ just before an opening—we’re unpacking the boxes, we never think we’re going to be on time, and the technology isn’t ready. At Facebook, we had pizza boxes everywhere, Nate was sleeping on the floor, and we were going to open the clinic in five hours—and somehow it was all beautiful, calm, and peaceful at 9 o’clock in the morning when everyone came storming through the door. But if anyone had seen it during hell week (or mere hours before opening), they would have found us rushing out the back door to hide the boxes. It was crazy.
At Apple, we had been in a little two-room clinic but were prepping for a move. The client wanted us to see patients until 5 PM on Friday, and then turn around and start to see patients in the new center the following Monday. Rich, who had moved back to Southern California at this point, came up and asked if we could do it and I said, “Sure, we’ve ordered the pizza and we’ll be here all weekend.” Nate, Rich, and Scott had passed this skill on to me, how to power through a weekend, nail the dress rehearsal, and be ready for the opening with a tiny little army. This is where I learned ‘servant leadership’ in practice, with even Scott (along with everyone else) taking out boxes to the trash at 6:30 in the morning. That’s a vivid memory for me, him with his arms full of boxes heading out the back door because the patients were coming in the front door.
These are absolutely some of my best memories. A lot of the new team members won’t experience that because now our talented implementation and launch teams roll them out like clockwork.
If you weren’t at Crossover what would you be doing?
I do break – well, bend – a lot of rules, and I’m not sure many people know that about me. But that is what keeps me energized. I just turned 60 and I never thought I’d be working this hard at this stage, but because I took ten years off, I kind of feel I have so much to make up for. I think if I wasn’t here, I’d be raising money for autism research. I don’t think there’s a lot I can do for my daughter, but there’s a strong genetic component, and I have three other children and my siblings have children, so I will always be curious about autism. I have some ideas about what causes it. I also still volunteer at the Children’s Health Council at Stanford so I’d probably be doing more of that.
Early on, I was banging down Stanford’s doors, asking for more information and saying, “You’re Stanford! How can you not be further along than Rain Man? Why don’t you know more about this?” They remembered and asked me to come in and talk to parents on diagnosis day—or D-Day as they call it—when they tell parents of a 2-year old that their whole life is going to change forever. They want me to come in and help counsel parents, to let them know there would be smiles again, and I love doing that. I have always found such joy being able to bring light when people are just on the edge of darkness. It is where my heart always leads me.
Many thanks to Peter Heywood (one of our long-standing brand advisors and business consultants) who helped conduct these interviews.
Scott Shreeve, MD 