A conversation with Rich Liekweg, CEO of BJC Health System in Missouri, and Nick Barto, president of BJC Health System
In his 1995 debut book The Road Ahead, Bill Gates famously observed “we always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.”
While the impacts of the pandemic era and its aftermath have been well-documented, I’ve been thinking lately about just how much the outlook for health systems has changed over the last decade.
I recently had a conversation with Rich Liekweg, CEO of BJC Health System in Missouri, and Nick Barto, president of BJC Health System. Together, we explored how they’re confronting ever-shifting headwinds, their insights from BJC’s recent integration with Saint Luke’s Health System in Kansas City, and their current thinking on how to best engage and inspire their people.
Dan Clarin: What do you think is the most important thing that's different about leading a health system now—not just compared to pre-Covid, but compared to 10 years ago?
Rich Liekweg: The intensity of the headwinds in 2025 are significantly more severe than they were in 2015. Some of the issues are still the same: for instance, the importance of workforce and payer relations. However, the severity of the labor shortages, the changing landscape and relationships with payers, and the cost of the inputs relative to what we were dealing with in 2015 just seem to be more intense. And that means we must be more strategic in our planning.
Nick Barto: On top of those issues—and probably because of them—the need for speed in terms of reaction time has increased exponentially. We have to be even more nimble in response to workforce issues given the outsized impact of labor challenges as a result of the pandemic and the role they played. There’s also a significant digital transformation underway with AI and social media continuing to grow. The need to accelerate and solve problems faster is ever more important.
Having a team in place that can operate in the moment but also look strategically around the corner is essential. That team also needs to be focused on increased competition. We've gone through a cycle over the last decade characterized by headlines that portend significant change, much of which never came to fruition.
But some of these changes have stuck, ushered in by many who see opportunity in healthcare given the size of our industry and its economic importance. We as health systems need to remain nimble in our approach to strategy and operations, and make sure that we're not complacent.
Rich: We have always been a “people taking care of people” business. Given the intensity of the labor shortages, it's become that much more important to focus on culture. How do you win the hearts and minds of, in our case, 44,000 caregivers? How do we differentiate BJC from others in the market?
It's hard to differentiate if you're just competing on wages and benefits. The amount of quality time one spends as an executive on developing and embracing talent, meeting the talent where they are and understanding where they want to go has become much more important.
Ten to fifteen years ago, we focused much of our efforts on operating hospitals. While we still provide a lot of hospital care, we are much more focused on developing the post-acute care side of the business than we were in 2015.
That shift and growth has required us to function much more as a truly integrated healthcare system, not as a federation of component parts. When we face the market, our consumers, our customers want to experience us as a fully integrated system, not as just a physician's office or a children's hospital or a community hospital or a big academic hospital.
Dan: Given all these different challenges, it would be easy to get caught admiring the problem and then get paralyzed and not make decisions. I’ve always admired that your leadership team is decisive but not hasty. What do you think enables that?
Rich: Our organization has always valued being incredibly intentional in how we lead, where we focus our efforts and being true to our purpose and values. We focus on daily operations and are deliberate about which strategies to pursue and why. We spend significant time as a leadership team anticipating, assessing and scenario planning, so we don't get caught by surprise.
Nick: If you have a homogeneous leadership team, you can tend to migrate to the same decision point based on shared experiences. There’s a diversity of thoughts and experience on our team, whether that's working in for-profit healthcare or inside and outside of healthcare. We have members of our team that came from multinational manufacturing companies, academic medicine, and more community-based health systems. I think that diversity makes for a more effective team.
Once you're in the room, everyone is working together to help each other make decisions. At the same time, we don't engage in groupthink: we’re very intentional about how we make decisions and who makes decisions.
Rich: In 2015, we were making strategic decisions at the local level. In 2025, strategic decision making occurs at the system level with input from our hospital presidents, our medical group leaders, our colleagues at Washington University and the board. We are going to win by having a more integrated approach in the marketplace.
Nick: It's important also to be aware when you have gaps in needed expertise, especially when a broader perspective is critical. In those situations, it can be beneficial to utilize third parties in a very targeted fashion. That's the type of work we value doing with you and your team from Kaufman Hall. You don't want to become overdependent on any third party—it’s important to own it—but their role as a sounding board and to help in select situations is important.
Dan: You’ve made it through a very successful first year of integration with Saint Luke’s. What would you attribute your success to so far?
Rich: The two organizations and cultures are very similar, which proved to be very helpful. We also were very purposeful in terms of how we structured the transaction, and we developed a very good 12, 24 and 36-month roadmap that we have adhered to.
As part of that roadmap, we made a conscious decision not to focus on clinical integration, given that we’re about 250 miles apart from one another. That also gave us the capacity to focus integration activity across our shared services, and the team's done a remarkable job executing that game plan.
Nick: We also committed to our Board and teams that we would prioritize staying focused on daily operations in the communities we serve. It’s easy to get distracted when you're doing new things and growing and to ignore the things that have made you great. We brought two great organizations together—and we made a commitment to our Board to not backtrack in any area.
Rich: When we were discussing the integration with the Board, we called out that we would do no harm to the underlying purpose and mission of the organization, which is ultimately about caring for our communities one patient at a time. As we were integrating shared services, we needed to make sure that we were continuing to advance access to care, hitting our quality goals and metrics, and ensuring we were continuing to invest with our community partners in improving the health of the community.
Nick: Given that we have two very different markets, reflecting on what made each of us great and not having the assumption that everything is transferable was critical. There are certain lessons you can bring from one market to the other. However, you also have to study those markets pretty intently to make sure that you're not applying operating principles or strategies that were developed in one market but don’t apply elsewhere.
Dan: Is there anything kind of unexpected or a little bit surprising so far about having two markets that are different from each other?
Rich: Yes, we learned that we can't take the playbook that we've used in St. Louis for the past 30 years and say, “let's execute the same playbook in Kansas City.” We have different assets in each market. We now have an even deeper understanding of that, and the go-to market approach in Kansas City will look different than St. Louis.
Nick: Missouri is unique in that the two largest cities in the state border other states. But while both of our core markets are in Missouri, the border states are very different in Kansas and Illinois in terms of rules, regulations, and different Medicaid programs.
Dan: What is one thing you’re both focusing on as a people leader in 2025?
Nick: As much time as you spend with your team, you probably need to do it more. You need to diversify what you're spending time talking to them about, talking about culture one day and strategy another day. Knowing the competition for talent, as a people leader you need to do what you think you need to do and then do a little bit more.
Rich: Our responsibility is to serve and help lead 44,000 individuals. As for 2025, a focus is on our team members and their perspectives: what does all this mean for them?
We are also spending more time on succession planning and leadership development. We want to make sure we're meeting our people leaders where they are and helping them continue to be the best leaders they can be, so they can do the same with their teams. As Nick said, it's then about checking in more frequently. How are they doing? What do they need? How can we be more supportive as we continue to grow and develop?
As we said earlier in the conversation, we are in the people business. Caring for our people and our patients is the most important work we do.
