Dr. Jean E. Johnson - Healthcare MBA GWU
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Dr. Jean E. Johnson

Founding Dean and Professor
The George Washington University
School of Nursing

Future of Nursing: Business + Care-giving


Dr. El Tarabishy: Hi. We are privileged here to have Dr. Jean Johnson, a professor and served as a founding Dean of the School of Nursing from 2010 to 2014. She provided leadership in the establishment of the School of Nursing by the Board of Trustees in May 2010, and has led the School of Nursing to a ranking among the top 50 nursing schools. This is good stuff, guys.

Prior to serving as Dean, Dr. Johnson was Senior Associate Dean for the Health Sciences programs. During her time, she expanded the Health Sciences programs from a small student enrollment to nearly 1000 students, and added several important programs including the Doctor of Physical Therapy as well as the Clinical Research Administration, and the Nursing programs. Dr. Johnson, thank you for coming.

Dr. Johnson: I’m very glad to be here.

Dr. El Tarabishy: So, we’ve been interviewing a lot of different experts and then what I call them, interpreneurs, entrepreneurs, researchers, educators, from the university. And you come with an interesting background. You are both a professor and a founding Dean of the School of Nursing, so I consider you an entrepreneur.

So, let’s just talk a little bit about founding the School of Nursing itself, some of the highlights and the logic behind it, the rationale behind it, the beauty of it.
Dr. Johnson: Well, [laughs] I would agree, I think it takes sort of an entrepreneurial spirit in terms of founding a school within a fairly traditional university, you know, that already had nine schools in it. The rational for it is that the George Washington University has an academic health center. I mean, it has medicine, it has the health sciences programs.

What it didn’t have was nursing, and nursing is the largest health profession in the world, actually. And just in the U.S., there are 3 million nurses. So, not having that educational component, you know, really, I think was an issue in having an academic health center. The challenge was building the nursing programs, you know, basically from the ground up.

And we did have quite a bit of help because we could leverage, you know, the health sciences programs, the physical therapy, the physician assistant, the clinical research administration, because we had developed core courses for those graduate programs. And those were the courses that we leveraged for, you know, being the core of the nursing education.

So, we started as a department, and then it became very, very, clear, and made the argument to the medical center and university administration that if nursing was ever to come into its own, it had to be a school, and that it would affect our ability to raise funds, it would affect our ability to be ranked, you know, in the top schools. And even since the 50, the rankings have improved even more. You know, the programs are really within the top 35 schools in the country.

So, being able to be visible and being able to raise funds and being legitimate. You know, if we wanted to recruit the best of the best faculty, they’re only going to go to Schools of Nursing where nursing has a prominency, you know, instead of being sort of three steps down in an administrative structure that really had no voice, you know, in decision making.

So, made those arguments to the administration, made those arguments to the faculty, and made those arguments to the Board of Trustees. And they agreed. [laughs]
Dr. El Tarabishy: [laughs] Yes. I know we talked, I think we’re almost dating ourselves now, four years, when you came to the School of Business. And you were making the case or saying we need to combine forces, we need to think collectively about the business side for the nursing careers.

Dr. Johnson: Yes.

Dr. El Tarabishy: And vice versa, the nursing careers need to understand business in order to propel. So, let’s talk about the future of business or the intersection of business and nursing together. How do you see it? You are in the founding hat, there. You were being very entrepreneurial, you were connecting the dots.
Dr. Johnson: Yes. Yes. I think that business is a very big and important piece of both knowledge and skills that all health care professionals need to have today. In fact, I was just having a conversation this morning with a group of Deans, that health care has changed so dramatically over the last 10, 20 years. We have to pay a lot more attention to cost effectiveness of treatments, we have to pay a lot more attention to efficiency within health systems.

And that takes understanding the business, it takes understanding the dollar flow, and if the health providers don’t understand the dollar flow, you know, we’re at a really big disadvantage in understanding how to leverage finances to improve care, how to leverage other types of resources to you know, really meet the needs of patients and large populations. I mean, bottom line, health care’s a business.

Dr. El Tarabishy: That’s very interesting. I know we talked about some of the courses that you were interested in, so let’s get into them. We talked about entrepreneurship, which is why I threw out the word entrepreneurship. As an entrepreneurial founding Dean of the nursing, talk about entrepreneurship and the health care industry itself, and in particular, nursing. And you see the opportunities that are coming there, or colliding, if you may.

Dr. Johnson: Yes. I mean, nurses are uniquely positioned because they are on the frontlines. We are all on the frontlines of the direct care with patients. I mean, nurses have probably the best view of the interface of the health system with individuals. In that interface, every day we see things that could improve care, that could be done differently — should be done differently — in terms of managing, you know, the error rate in health care.

And it takes being an entrepreneur to not just see the possibilities, but to act on the possibilities. To actually create, perhaps, different ways of providing services, different ways of providing products, creating new products. And yet, nurses see this every day, but they don’t know how to take their ideas to the next step.

And it’s just so important for nurses to be really entrepreneurial, you know, in being able to change the health care system, because what we know now is that medical error, for instance, is probably the third leading cause of death in the U.S.

Dr. El Tarabishy: Wow.

Dr. Johnson: And that’s big.

Dr. El Tarabishy: That’s very —

Dr. Johnson: That’s very big. And nurses can change that, and nurses can change that not just through the spirit of wanting to do better and provide better care, but being entrepreneurial in terms of changing systems, creating products, you know, creating the way we believe we should be delivering care.

Dr. El Tarabishy: I was reading an article and, recently, I think it was in the New York Times or the Wall Street Journal. They were talking about the Uber-ing of the workforce.

Dr. Johnson: Yes.

Dr. El Tarabishy: And I was really intrigued. They’re saying even though Uber is a model itself that was on the peripheral, now it’s moving more and more into different workforces. Manufacturing.

Dr. Johnson: Yes.

Dr. El Tarabishy: Health care providers, right? And I was interested to read more about it saying how’s this affecting the workforce of the health care when there’s this Uber model, and what I mean by an Uber model is for instant allowance for the workforce to come in and say I’m a knowledge worker, right? You have a need, I can switch and go here and there and you need to compensate me and hire me based on my skill set. How do you see that intersection happening?

Dr. Johnson: Well, within nursing in a sense, there has been an Uber system. You know, because almost every large health system has basically nurses on call. You know, or nurses who are part of a per diem pool, you know, that can be called into service, or part of a different organisation that contracts with hospitals that provide, you know, nurses with specific expertise.

Now, you brought in an really interesting point about, you know, almost the flexibility of the workforce so that they could go from one place to another place. That actually is a really big issue, you know, in terms of nursing, because if you have a nurse who has been working in labour and delivery, for instance, and then try to put them into an intensive care transplant unit, those are different skill sets.

Dr. El Tarabishy: Yes.

Dr. Johnson: You know, so that is not perfectly, you know, flexible. But the flexibility gets into where we have pools of nurses who have, you know, expertise in different areas that can be pulled in as needed. And you know, nursing is still a largely female profession, and there are a lot of nurses who are raising families, want to work part time, and you know, being pulled in at certain times when they want to be, just like Uber drivers, when they want to be, already exists.

Dr. El Tarabishy: And there’s a dark side, or there’s potentially some limitations to Uber. I think there’s currently litigation happening in California in which the judges are saying all Uber drivers may or may not — I don’t know exactly what the rules were coming down to — but they were considered of employees of Uber and not contractors.

Dr. Johnson: Yeah, contractors.

Dr. El Tarabishy: Right. And that’s an interesting wrinkle, because that changes the whole spectrum of what is possible and what is not possible.

Dr. Johnson: It does.

Dr. El Tarabishy: So the two articles are intersecting saying yes, there’s that ability or agility. At the same time, employees have rights.
Dr. Johnson: Yes.

Dr. El Tarabishy: Right. And you see that at some point, this needs to be handled. Not just with nursing but with health care providers as well. What’s your take on this, and how do we move forward, kind of trying to have both systems happening?

Dr. Johnson: Well, I think that we’re in a time of trying to figure these issues out. And you know, it’s going to take legal challenges, it’s going to take clarification of what really constitutes being an employee and what constitutes being a contractor. And yet there are clear, I mean, there are differentiated, you know, roles. And I, to be honest, I’m not sure how this is all going to fall out.

I don’t know how California, you know, will end up deciding about the status of Uber drivers, but it does have a reasonable impact in terms of the health care workforce because benefits are a really important piece of, you know, sort of income, so to speak. And contractors generally don’t have benefits through a company.
And that’s one of the reasons that nurses sometimes affiliate with a company that then, the company contracts with the health care organisation so that the nurses that are called in actually do have benefits from this other organisation, although they don’t have the benefits from the health care organisation. So you know, the complexities are. . .

Dr. El Tarabishy: More and more.

Dr. Johnson: Yes. More and more. And you know, they will need to be worked out because I think that people are wanting to have, you know, certainly certain guarantees in terms of income and their own financial wellbeing. But we’re seeing more and more, you know, particularly in younger generations, the millennials, even the Xers, that they want to have more freedom in their life. They want to have a personal life. And all of this is going to have to be balanced.

Dr. El Tarabishy: If you come from a business side and somebody’s looking at the nursing cadre of experts, and looking at them as a potential resource or customer base, and I’m going to put you in a tough spot here —

Dr. Johnson: Okay, I can feel it coming. [laughs]

Dr. El Tarabishy: [laughs] What’s the nature — is there nature changing? Is there — I know you talked about work life, but what else was changing? Is their mindset changing? Is their expectations changing? Because it’s vastly evolving here. But you’re — I’m a business person and I’m looking at the nursing system itself, I’m looking at the resources there and the individuals, and saying what is it that other people don’t see as an opportunity that’s happen?

Dr. Johnson: You know, I think that within nursing, and this may not answer your question directly, but in an. . . I’ll get there. You know, people go into nursing generally not so much because they see it as a job, as a high paying opportunity, because nursing is not one of your highest paying professions. Although it pays reasonably well.

They go into it because they want to be a care giver, they care about people. They care about relationships. And that’s, that is the heart of nursing, you know? That’s one of the important aspects of nursing is the caring. The other is the science base, you know, for providing nursing care.

The issue, I think, that’s evolving, you know, and there’s a lot of us that are kind of concerned about it, is that within the business environment, you know, there’s a lot of pressure to take care of more patients, there’s a lot of pressure to cut costs, there’s a lot of pressure on nurses to do more. There’s more paperwork, there’s the electronic health records, there’s, you know, a lot of administrative detail to look at. There’s a lot of collecting data for quality improvement projects.

And how do you balance that with the real caring part of nursing? And I think that some people are looking at nursing these days and kind of going, so how can we really continue to save that caring piece while all of these forces on the business side, are really important and are incredibly impactful?

So, you know, I think that where people look at nursing in the future, you know, what they may have a little bit more trouble seeing is the caring part, and they see more the technical science-based part along with all of the tasks that need to be done. And I think that nursing cannot, cannot lose that caring piece. And that’s going to be the challenge to us as a profession, and I’m hoping that business folks, entrepreneurial folks, business set, understand that.

Dr. El Tarabishy: Yeah. I’m hearing you say that there’s a major empathy part.

Dr. Johnson: Yes.

Dr. El Tarabishy: And that cannot be quantified in business, even though there’s more pressures for the business to create efficiencies. Empathy, you cannot create efficiencies in empathy. It’s from the heart.

Dr. Johnson: Right. And for instance, one of the issues that actually is prominent right now has to do with the patient experience of care. Every hospital has to send out, you know, to a sample of hospitalised — people who had been hospitalised — a survey about what their experience of care was about. And in that, there are specific questions about nursing.

The questions don’t relate to, so did the nurse start your IV, you know, painlessly? Did your nurse listen to your lungs appropriately? You know, those aren’t the questions. The questions have: did your nurse listen to your concerns? You know, did your nurse, you know, respond to you in a timely way?

It’s the questions that really relate a lot to the caring part of the relationship, and that’s an incredibly important part even being integrated into the payment system of health care. So, you know, there are now forces at play that sort of reinforce that caring component.

Dr. El Tarabishy: On top of this, and I teach a course at GW, Electronic Medical Record, and from experience, what I’ve seen a lot of the worst practices that happen is when they divide up the groups. The nurses into one group, the doctors, administrators, and they don’t allow them to talk to each other. But the success stories are when they are all collectively talking to each other.

But that raises a major point. The major point is the nursing now has switched just from being an individual that is targeted doing specific roles, but being in a leadership position and a management position and implementing a major electronic medical record system The roles are changing. What’s your take on this, what’s your opinion on this? When things are evolving in that sense of the voices of individuals are changing.

Dr. Johnson: Well, I think that the voices are changing. You know, and I want to say a couple of things about actually electronic health records, inter-professional team work, you know, because nurses are indeed often in charge of quality improvement projects, implementing the electronic health record. Care processes, policies, those kinds of things that go on in the health system.

And yet, you know, every nurse in a leadership position or every physician in a leadership position, or PA or physical therapist or whomever is in the leadership position, has to be able to function well within a team because nothing happens because one individual does something. That’s just not how the world of health care works these days. I mean, we need to have teams of people figure out how they’re going to be deployed to take care of populations of people.

You know, how they’re going to be deployed within a quality improvement project. Who’s going to do what, when, where, you know? So, the leadership abilities are changing. I think it’s absolutely clear that nurses need to understand leadership and change and resistance to change, to a greater extent than exists now, because we have a system where because nurses were really good clinicians, you know, they get promoted into management positions without having the support and the knowledge necessary to be leaders.

And so, you know, that’s important. Would also like to say about electronic health records, [laughs] because you opened the door, you know, electronic health records right now are, you know — as you know, you’re teaching it, I’m probably preaching to the choir — that they’re at the very infancy stage. You know, they’re almost still tied into the written record, you know, but people enter data into a system, you know, and so that makes it easier to extract data.

Although we haven’t exactly gotten to the place where meaningful data is easily extracted. But you jump ahead and you kind of go, so, so what is this electronic health record going to be about and be able to do in the future? Because it’s got to evolve from simply, you know, an electronic version of a hand-written record.

It’s got to be used in ways that really aid decision making in health care, that provide, you know, immediate feedback to health care providers about the status of patients. You know, you look forward and you see Watson, IBM Watson, you know, that has so much data. Yes, we’re talking artificial intelligence. And please don’t ask me what I think about the future of artificial intelligences in health care [laughs] because I honestly have no idea. I just know that it’s going to be an issue.

Dr. El Tarabishy: Yes, when you can an artificial intelligence to diagnose an ailment that you have based on millions of records, but are you still trusting that artificial intelligence with a diagnosis?

Dr. Johnson: From what I’ve read, it’s more accurate than a human diagnosis.

Dr. El Tarabishy: That’s scary.

Dr. Johnson: It is scary. But then when you think about it and you think about what we were just talking about in terms of the relationship component of health care, you know, but then having the ability of really creating a way of accurately diagnosing and managing diseases, and then the whole issue of personalised medicine, you know, based on genomics and whatnot. I mean, we’re heading into a totally, totally different way of approaching health care, which is wonderful.

And you know, the, you know, misdiagnosis is a huge problem in health care. I mean, if you think that that’s something that is a refined science, it’s not by any means. And that’s why I think that, you know, with all of the millions and millions and billions of pieces of information that, you know, for instance Watson or other, you know, artificial intelligence programs can accumulate, can be more accurate, you know, with their diagnosis.

A human, you know, you can only read so much every day, you know, in terms of new information.

Dr. El Tarabishy: You are opening up a big can of. . .

Dr. Johnson: [laughs]

Dr. El Tarabishy: So, I guess the question is, can you see, 20 years from now, an artificial intelligence nurse and doctor?

Dr. Johnson: No. Well, yes, I can.

Dr. El Tarabishy: [laughs] No, yes?

Dr. Johnson: [laughs] You caught me. I can see artificial intelligence greatly assisting doctors and nurses. But it again is that relational component, you know, that —
Dr. El Tarabishy: The empathy.

Dr. Johnson: Yes, the empathy, the caring, the, you know, making sure that the educational process takes place, you know, those kinds of things. So, it’s kind of like online learning these days. You know, content can be put online. I mean, you know, anybody can read it, and body can listen to it, you know, there’s lots and lots of courses out there.

But, you know, one of the really important aspects of it is the together learning and the supervised learning and the feedback and the challenging. And the, I think the same will continue in health care. I think it will remain relational.

Dr. El Tarabishy: One last question. And this —

Dr. Johnson: Okay.

Dr. El Tarabishy: About you, because I think you’re an entrepreneur in disguise.

Dr. Johnson: [laughs]

Dr. El Tarabishy: In the School of Nursing. What are you working on now?

Dr. Johnson: Ah! [laughs] Actually, I’m working on a number of different things. One is that I’m actually just finishing up a massive open online course on health care quality improve.

Dr. El Tarabishy: A MOOC.

Dr. Johnson: Yep, a MOOC. And I’m also working — I have a Fulbright scholarship, and I have been working for a number of years and continue now through the Fulbright to work with the University of Cape Town in South Africa to develop the first graduate level pediatric clinical Master’s program in nursing in all of sub-Saharan Africa.

Dr. El Tarabishy: This is amazing.

Dr. Johnson: Which is — it is amazing. And I’m working with the most wonderful group of people in terms of doing this. And I’m also, I have become a certified executive coach and I have people that I’m working with in that capacity and I’m working with the School of Nursing to figure out how to integrate the executive coaching into particularly the doctoral level program, so.

Dr. El Tarabishy: I’m telling you, you’re an entrepreneur in disguise.

Dr. Johnson: [laughs]

Dr. El Tarabishy: [laughs] Thank you so much for your time.

Dr. Johnson: Well, thank you. It’s been a pleasure.