Our episode this week is a conversation with long-time University of Iowa faculty member, Tom Vaughn. As he prepares to retire from a distinguished career, Tom talks with Eric and Anya about the changes he’s seen in healthcare and health administration and offers academic and career advice for students.

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Have an question for our podcast crew or an idea for an episode? email anya-morozov@awalker11

Eric Ramos: Hello, everyone. Welcome back to From The Front Row, brought to you by the University of Iowa College of Public Health. My name is Eric Ramos, and I’m joined today by Anya Morozov. If this is your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone both in and outside the field of public health.

Eric Ramos: Today, we’re talking with Dr. Tom Vaughn, an associate professor of health management policy who’s retiring the day we planned to air this episode. Fueled a master of health services administration degree, and a PhD in health services organization policy in the University of Michigan, and has worked the University of Iowa in various capacities since 1995. Today, he’s on the show to chat with us about his career, his research, and some advice for the future students. Welcome to the show, Tom.

Tom Vaughn: Well, thank you. It’s nice to be here.

Eric Ramos: So Tom, can you just walk us through your career path a little bit just so we can get a good picture of where you came from, how you got to today?

Tom Vaughn: Sure. I started off when I was an undergrad as a respiratory therapy technician in Ann Arbor, Michigan at a hospital. And I did that for about three years and then by some odd circumstances, wound up working in their personnel department and had a meeting one day with their administrator who’s asked me if I’d ever thought about hospital administration. I thought, oh, what the heck? So I applied and got into the MHSA program at Michigan in 1975. And so I did that for a couple of years. And then when I finished, I went to Hillcrest Hospital, which is in Cleveland, Ohio, and worked there for about six years as director of patient services and also doing strategic planning. And it was an interesting thing. They took out a layer of management of which I was a part, which taught me something about recovering from bad circumstances.

Tom Vaughn: I wound up, after that, getting a job at Mercy Hospital in Clinton, Iowa, and was there for about three years, and I got intellectually restless. I like ideas and concepts and theories, and I started thinking maybe I should go get a doctorate. And then I also thought if I get a doctorate, I can train a lot of people to run a lot of healthcare organizations rather than trying to run one myself. So I decided I would do that. So I went back to graduate school, and I was there actually for about nine years, which is a long time for most people to be in a doctoral program these days, but I’m a little slow. And then I came here in 1995 and I’ve been here ever since.

Anya Morozov: Well, first of all, I’m sure you learned a lot during that nine year PhD process, and also I’m sure it was probably informed by your work, practicing in healthcare administration. So can you talk a little bit more about how your experience practicing as a healthcare executive informed your research career?

Tom Vaughn: Yeah, a couple of things. Number one, it gave me some insight into healthcare organizations and the complexities of those organizations, because you’ve got so many different professions, so many different folks with different training. You’ve got the external influences of federal policy and state and local policy and payment mechanisms and all those things. So it gave me a sense of that complexity and the balances of trying to meet the needs and expectations of different stakeholders and balancing those off in pursuit of the primary goal, which is namely serving the public and serving people who need healthcare. And so that helped me think through what the things that had helped me develop my philosophy of research, which is to try to do research that either improves our ability to care for patients in healthcare organizations or that makes it easier and more fulfilling for the staff working in those organizations.

Eric Ramos: Obviously throughout your career from the beginning to now, things have changed so much, especially in the last two years, just with the pandemic itself. So much has happened in healthcare just in the past two years, but over the length of your entire career, how have you seen the field of health management policy or just the career of health administration change, or what are some things that you’ve seen you’ve had to shift focus to over the years?

Tom Vaughn: Yeah, it’s interesting. In some ways it’s been episodic for one of a better term. So for instance, I started working in the field after my master’s degree in 1975, and in 1984, they introduced what they called, at the time, prospective payment system, which basically we now think of as DRG or reimbursement, which is basically a reimbursement that the government, for Medicare, government sets based on the diagnosis that someone has. And they’ve got a whole waiting system. Eric knows this, but Anya, you may not, they’ve got a whole waiting system that tells how much one procedure, how much effort it takes versus another diagnosis in order to take care of those patients.

Tom Vaughn: And that really through the industry and a tizzy, if you will, because prior to that, they had what was called usual customary and reasonable rates, which basically meant what everybody else is charging, you’re allowed to charge that much. And so it caused people to start thinking about, okay, what are our profitable service lines, rather than just who are we taking care of, and let’s do a good job. Where do we need to focus in terms of the bottom line, as well as how we’re going to take care of the patients?

Tom Vaughn: And then another thing that has been really interesting is the growth of systems and the impact of systems. So you’ve got perhaps distant administration for the system who is influencing the decisions you make at the local organization. And so that growth changed things. And then in 2000 was the book came out, To Air is Human, in which some folks estimated that something like 98,000 persons a year died because of hospital misadventures and healthcare misadventures.

Tom Vaughn: And that was followed closely by another book, Crossing the Quality Chasm, which talked about, okay, what do we do about this? How do we think about the healthcare delivery system as a system? And what are the pieces within that system, how do we fit all those pieces of the system together to improve the quality of care? That drove the concept of the triple aim, which Don Burwick is really famous for it. And he wrote a piece with Nolan and Woodington about that. And the idea behind the triple aim is you want to simultaneously, I’m looking at some notes, forgive me for that.

Anya Morozov: No, that’s good.

Tom Vaughn: Improving the experience of care, improving the health of populations and reducing the per capital cost of care. And that really drove a lot of the work around improving quality in healthcare institutions, but also in terms of the efficiency as well. And so a lot of organizations started adopting efficiency and quality mechanisms from industry. So for instance, lean and six sigma and things like that became very popular.

Tom Vaughn: Another big issue, which was really on the cusp when I was just finishing up my masters, but really didn’t grow a whole lot till later was the role of physician executives at the senior level of organizations and their role in terms of helping think through not only quality, but also strategy in terms of the organization. Then along came the Affordable Care Act in 2010. And then that drove all the changes that are so prevalence right now, like accountable care organizations, informatics in terms of population to health management, the coordination of care across levels of acuity and all those things, the emphasis on those. Those were always happening, but the real emphasis…

Tom Vaughn: So for the accountable care organizations, for instance, there are financial incentives to manage care across the levels of acuity and across different organizations, more than ever before. And then of course, we got our good friend COVID-19 more recently, and that’s caused people to really rethink their care processes in healthcare delivery organizations. It’ll be interesting, just to side comment, to see how much those really persist, those changes that people made. Some folks are thinking that they will, some people are not so sure. So that’ll be an interesting research project for somebody else to take on in the future.

Tom Vaughn: And then of course, one of the other things there was the growth in telemedicine, and we’ve got a couple of our colleagues here in our department have a major research center looking at telemedicine and issues. So those are some of the things, and then it’s how we adapt as executives and as managers to each of these little changes or big changes, how we adapt to them causes us to be thinking about, okay, what do we have to pay more attention to as we try to manage organizations?

Eric Ramos: I just think it’s really interesting how you talked about PPS and that fee for service DRG system, how that really threw things for a tizzy back then, but how we’re now talking about value based health and how that’s going to affect the system now, how we’re going through a new change. And even now, how people are thinking of the quadruple aim, rather than the triple aim. It’s interesting to see how those ideas evolve and how they’re at the forefront now just as much as they were back then. I’m interested to see how that’s going to evolve when I’m older in my retirement age, how I’m going to look back at that.

Tom Vaughn: That’s a very good question. And again, I think that in some ways, the quadruple aim makes more sense in terms of at least the things that I’ve always been interested in, which is namely not just about how we’re taking care of the patients, but also how we’re taking care of the staff. And I think COVID helped emphasize the need to take care of our staff and clinical and non-clinical, both, and how to take care of them so that they can be protective and they can feel like they’re fulfilled in what they’re doing.

Tom Vaughn: So my sense is that’s going to be long term. Of course, all the nuances, and then another thing that I didn’t even think to mention in terms of changes is some of the other people that are getting into healthcare. Well, they’ve been in it already, but CVS and Walgreens and the major emphasis they’re putting on. And then some of the other corporations like IBM and Apple, and those folks who are trying to make some inroads into healthcare. And so it’s those things, it’s going to be interesting to watch. Some of those are already falling apart. So we’ll see what’s going to happen in the future. I think it’s going to be exciting times for the folks going into the field.

Eric Ramos: I agree.

Anya Morozov: Yeah. I think the field is evolving quickly. I think the part that really resonated with me was the focus on systems thinking, because I think that’s true in a lot of other aspects of public health as well as recognizing everything is this big system and how changes in one part effect changes in another.

Tom Vaughn: Yeah, one of the things I miss, just mentioned in passing a minute ago is population health. And I’m personally convinced that if we’re going to fix the healthcare delivery system and improve the health of the population, which is what public health is all about, we need, in the delivery side, to be thinking more and more about population health, and population health in the sense of our community, the community we serve, not just the people who happen to walk through our doors, and how we’re going to integrate and supplement the things that public health professionals are doing so that we’re working in conjunction with one another more effectively.

Anya Morozov: Yeah. While I am just starting my career, you have probably conducted many studies over the years. So are there any studies you’ve conducted that you’d like to highlight?

Tom Vaughn: Yeah. A couple on this, again, goes back to the whole issue of my philosophy of the kind of research I want to do. One of which is a thing that I did with some colleagues, both here and elsewhere called the Hospital Leadership and Quality Assessment Tool, something we created based on the literature, and then we’re able to administer it to over 400 hospitals in nine states to find out what some of the key organizational characteristics that seem to support quality of healthcare were, and it was really a rewarding piece of work for me.

Tom Vaughn: Another one, again, at the more micro level for one of a better term is the work that we did with Team Steps and Team Steps’ evaluation. Team Steps is a program that was developed, I think, by the American Institute for Research and the idea behind it is to work with healthcare delivery teams to improve their functioning. And it’s got a whole educational component to them, like a two or three day workshop that people go through. And then the ideas, they bring that back to their organization and implement it.

Tom Vaughn: We got a grant to evaluate its implementation in several organizations here in Iowa. And it was a fascinating process to do that. And it was also interesting to see where it worked and where it didn’t seem to be working and why it seemed to work, why it didn’t seem to be working. But nevertheless, it was rewarding to be involved just in that, because it was, again, the idea of how to help people do their work more effectively and feel more committed to it.

Tom Vaughn: I did another thing more recently because of where we sit in Iowa, which is, as you both well know, very rural, was some of the work that my boss, Keith Mueller has through his Rural Health Policy Institute around the impact of the Affordable Care Act on rural healthcare and on rural healthcare organizations. And particularly, we looked at accountable care organizations that were involving rural health organizations, or that were created in rural communities for rural communities. So particularly one up in Maine, which was really fascinating because Maine’s a huge state and in this accountable care organization, they were trying to serve people in four different places throughout the state. And just to see how they were trying to make that happen was just fascinating.

Eric Ramos: Yeah, it’s definitely really fascinating. Especially intrigued by the Team Steps. I know we mentioned team Steps A lot at Iowa, both at the Patient Access Center, and now my finance internship, they mentioned scheme steps and things they’ve learned through those programs. That was really interesting.

Tom Vaughn: I’ll have to spend some time talking with you about that. You can educate me.

Eric Ramos: Good. I guess, about educating the public, what is something or some advice that you’d want to tell the general public? If you could pick one thing, what is something you would want to tell the general public to know about your field of research, but about health administration in general?

Tom Vaughn: Yeah. As I mentioned, my focus of my philosophy has to do with organizations and how organizations impact both the people we’re taking care of, but also the people who work there. And if you think about it once, virtually anything that we accomplish or that we mess up in healthcare and in other sectors is through organizations, that they happen in organizations or through organizations. And so that’s why I’m so interested in organizations. And I think in terms of the importance about this field is that if we’re going to improve healthcare, and if we’re going to improve health in general, we need to understand how to govern organizations, how to lead organizations, how to create cultures and organizations that support the people who work in them. And so that they’re more effective and feel more engaged in what they’re doing and proud of what they’re doing.

Tom Vaughn: And in a lot of ways, we don’t get down into that level. A lot of the things that we do look at in terms of research are at the policy level, but policies have to be implemented somehow. And so that’s why organizations are so important, studying organizations is so important.

Anya Morozov: Yeah. That is something I don’t even think about as often as I should probably is… I have thought about the policy level a lot or individual and interpersonal level, but really it’s true that if a policy is in place, but it’s not implemented by the organization, it’s not really going to have the intended effects.

Tom Vaughn: And even internal policies, the same thing. If you’re trying to do something within the organization to change how you deliver care, again, you’ve got to get buy-in from all these folks, and you’ve got to have the appropriate internal policies in place. You have to have reward structures so that people are recognized, and those don’t have to be financial, necessarily. They can be just recognition of somebody having done a good job, but you need something to help motivate folks and to help them understand, and also to give them the opportunity to experiment a little bit, and to try something a little bit different, as long as it’s focused on your outcome, what you want that to be.

Anya Morozov: Yeah. I know a few weeks ago we interviewed Joe Ty and he was talking about invisible architecture. And this seems to be a lot of what you’re talking about too.

Tom Vaughn: Joe Ty, by the way, was an alum of our program. And he used to teach a different course I’m teaching right now, but he used to teach several segments in that course. So I really like Joe a lot.

Anya Morozov: Yeah. Yeah. He was fun to talk to, for sure. So moving toward a student perspective, do you have any advice for potential students who are interested in the field of health management and policy, or are maybe like Eric and getting started in it?

Tom Vaughn: Sure. I guess that I would just say that anybody that’s interested in and actually enters the field, this is one of the most important areas in life. We’re touching people’s lives in this field as a whole. In terms of management, the real role of healthcare managers is to make it possible for the staff to heal people and to make people’s lives better. So we need to begin with, obviously is to focus on learning everything you can learn in both in the classroom, but also through other experiences, that you get external experiences that you have an opportunity to engage in.

Tom Vaughn: And then don’t stop learning once you graduate, be involved with other opportunities to learn and to grow. Find a good mentor once you do graduate. And even while you’re in this program, find somebody that you can bounce the things that you’re learning in class off of and get their perspective on things. Again, because what we’re doing is helping other people protect lives and improve health is to be humble and to realize that’s what we’re there for. It’s the concept of serving leadership. We’re there to help other people be able to be successful and to do their jobs well, but boy, it’s a great, important field. It gives you a sense of satisfaction, that you’re actually contributing something to other people’s lives. And you meet some really neat people, some really smart, neat people.

Eric Ramos: Yeah. I agree. Even my, what? One and a half year now in the program, I’ve already met some incredible people and have learned a lot. So I’m excited to continue learning, can be that lifelong learner and going off that lifelong learner, what’s something that you thought you knew, but were later wrong about, Tom?

Tom Vaughn: I was thinking about that since you guys let me look at the questions ahead of time. And I really struggled and not because I know so much, but because I always have the self-doubts about what I think I know. I’m always worried that maybe I’m wrong. And so it’s a really struggle. My one son gave me a journaling book a couple years ago, and it had a title on the front of it, was Things I Was Right About. And so far I haven’t made a single entry into it.

Tom Vaughn: But anyway, one of the things though, just in the field that I can still remember when I was a master’s student, for our capstone, I had to write a paper. And at that time, this was in 1977, there were four, no six, excuse me, six proposals for universal health insurance in Congress that were being taken to Congress.

Anya Morozov: Wow.

Tom Vaughn: And I thought, sure, we would have universal health insurance within 10 years. And obviously I was wrong.

Eric Ramos: It’s so crazy, looking back at that, just saying how we have all so much, we’re always technically in the same place as far as certain things go. But I’m going to ask you one question just as a fun question, just not anything related to career just so we can get to know you a little more. That’s not has to do with health administration. Let’s see, let me ask you the question. What’s the best thing you’ve ever eaten that you look back and you think, wow, that was the best thing I’ve ever had to eat?

Tom Vaughn: Now that is an interesting question. First, I have to preface this by saying my partner, Lori, is one of the best cooks that I’ve ever met. And so anything that is exceptional is probably something that I’ve had at her house. Having said that, nevertheless, as a friend of mine and I went to a French restaurant in Chicago one time, and to be honest, I don’t remember exactly what we had, but it’s one of the few times that six weeks later, I could still remember how good that meal was.

Eric Ramos: Well, we’ll have to track down what restaurant it was.

Anya Morozov: Yeah, we certainly will. Man, going back to what you thought you knew, but were later wrong about and your feeling of being wrong all the time, I thought that would go away after a while, but I guess not.

Tom Vaughn: Yes. Yeah, it’s interesting you mention that, because I don’t know why it ran through my mind today, but that whole concept of the imposter syndrome, of do I really belong? Do I really deserve that? I think for some people, it goes away. For other people, they fake it until they make it kind of a thing. And then for other people, you just keep muddling along as best you can and hope things turn out well. And for me, fortunately they have turned out well, and I’ve been really blessed to be where I am for these past 27 years.

Anya Morozov: Yeah. Well you have definitely made some great contributions to the University of Iowa and the field of health management and policy overall. So thank you for that. This is a bittersweet part of the episode, but yeah, just thank you for coming on today and we wish you all the best in retirement.

Tom Vaughn: Thank you for inviting me. I hope that people enjoy listening to this.

Anya Morozov: I’ve enjoyed this conversation, for sure.

Eric Ramos: Yeah, I did too. Thank you so much, Tom.

Tom Vaughn: Thank you.

Anya Morozov: That’s it for our episode this week. Big thanks to Tom Vaughn for coming on with us today. This episode was hosted and written by Eric Ramos and myself and edited and produced by me, Anya Morozov. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcast, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at CPH-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious and take care.