I Thought We Were Winning. Then, We Got Fired: Essentials of Anesthesia Leadership

In this powerful and unfiltered episode, Dr. Joseph Rodriguez — CRNA, former state and national leader, faculty member, and host of Anesthesia Deconstructed — takes us inside the real lessons of anesthesia leadership.

From COVID-era disruption to contract losses, difficult boardroom conversations, and the relentless financial pressures of today’s anesthesia market, Joe shares stories that few leaders are willing to tell. Each story carries a hard-won lesson: why leadership is never just a title, how executive presence shapes outcomes, why data transparency can backfire, and how accountability transforms teams from fragile to high-performing.

We also dive into the frameworks that shaped his leadership journey — from Crucial Conversations to The Four Agreements and Five Dysfunctions of a Team — and how every leader can apply them to grow themselves, their organizations, and the people they serve.

This isn’t theory. It’s frontline leadership, with all the scars, pivots, and resilience required to survive in one of healthcare’s most disrupted specialties.

Whether you’re a CRNA, SRNA, or a healthcare leader navigating change, this conversation is a masterclass in turning setbacks into systems, failures into frameworks, and words into lasting impact.

Keywords:

Anesthesia, CRNA Leadership, Healthcare Business, Executive Presence, Leadership Lessons, Nurse Anesthesiology, Organizational Growth, Accountability, Professional Development, Anesthesia Contracts, No Surprises Act, Healthcare Strategy, Team Building, Crucial Conversations, Five Dysfunctions of a Team

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Transcript

super excited to have Dr. Joe Rodriguez on with us today. I have his intro. He's a founder and the chief development officer, which I'm hoping we get to hear what a chief development officer does, but he does that for anesthesia. He's played key roles in helping shape in the field of nurse anesthesiology, including that term nurse anesthesiology. He's the former president of Aizana, served on the board of directors of the ANA.

Planned anesthesia policy reforms at both the state and federal levels, both in government and within the AANA. He maintains a faculty position at National University. And where is that university located? Great, state of California. The northern half or the southern half? the university is located in San Diego, but it is the program is located in northern California. It was just there a little while ago in Fresno.

Just saying, just saying. He is also the primary host of the top ranked podcast, Anesthesia Deconstructed. His writings have appeared in publications such as the Washington Times and Anesthesiology News. Dr. Rodriguez is a regular speaker on topics related to business and leadership in healthcare. He's a fantastic advocate for the profession and good friend, and I can't thank Joe enough for taking the time to be on here with us today.

to talk about leadership in the anesthesia world. And excited to hear from Dr. Rodriguez. Take it away, dude. Thanks, Danny. Thanks so much, everybody, for being here. So I'm talking about leadership today, and if you remember one thing about leadership, about stepping into the gap.

Okay, it is not just a title. It is words. Okay, and it is words and actions that over time have an impact. We're going to walk through very specific examples of how this principle plays out.

So five years ago now, we were in the midst of COVID and the organization I was part of, the small size, CRNA organization, about 50, 60 people. remember right where I was, I pulled into my driveway and someone said, you need to check your phone. And the governor of the state was on, on saying, we're having this crisis. We're shutting down surgeries. And of course surgeries are what we manage from an anesthesia point of view. So this had very detrimental effects to our business. And we were

very worried, all we could do at that point, we got on a giant Zoom call and said, everybody, we're going to pay everybody as long as we have money. That's the truth, right? If you don't want to work during COVID, you don't have to. If you do want to work, we'll try to find you something to do. We're navigating this live. And then came a phone call. We were already covering a small office for an orthopedic practice. And this phone call was now for their crown jewel, their orthopedic practice.

And they said, we need you guys to come in. And we were like, great, because we need something to do. Right. And we were out, we were stoked. Right. It's look, I was just off being state president. My business partner was also a state president. We were all in on the team, CRNA. We were an all CRNA group at that point. We were, this is a very prestigious hospital right in the heart of town. We're like, this is awesome. Right. And the truth is it was awesome. It went really well.

And, you know, all of a sudden we're talking about how great being a CRNA is and how much value we're providing to this hospital, so on and so forth. And, you know, over time, over the next two, three months, we began to get into a normal rhythm. And we were like, this is amazing. We are so stoked. We had our contract in place. We never thought that they would think about replacing us at this point, because who else is going to do it? And to boot, this is the real sweetener. The group that left.

was a vehemently anti-CRNA group. They left because they had disagreements, they weren't getting along anyway. And that other group, treated CRNAs like garbage. Frankly, CRNAs didn't do nerve blocks, they couldn't stay late, so on and so forth. And so when we started this hospital, we changed the delineation of privileges, CRNAs were doing nerve blocks, it was awesome, right? And then we got called into a meeting and they were like, hey, we love you guys. And we're like, we love you guys.

We're excited to be here." And they said, we love you guys so much that, you know, as much as we love you guys, we can't be the only city in the hospital without an anesthesiologist. I'm sorry, the only hospital in the city without an anesthesiologist. And we were like, well, that's no problem. We'll get an anesthesiologist here. We'll have them flow. We'll have them help out. And we think it'll be great. And they said, ⁓ unfortunately, you know, that we actually want you to work with these anesthesiologists that we know.

And we were like, who's that? And it turns out it was the neighbor of the chief medical officer who is a partner and owner in an all MD group who had never worked with CRNAs before. And we were like, okay, that makes us uncomfortable, but we can probably work through it. yeah, let's have the conversation. Well, they're like, actually we're not going to have the conversation. ⁓ We just anticipated that you would not be willing to work with an anesthesiologist because you guys are so pro-CRNA. So.

we're actually going to have to cancel your contract. Like, what? Like, you know, we could, we could talk through this, right? I they're like, no, we're, actually already signed a contract. His name is Demetri. I, we've already given the contract to Demetri. was like, can't be right. Like, are you sure there's no way to work through this? Is there any possible way? And I was like, no, the, decision was made.

So that's a story. There's no resolution here. We lost the contract. We were fired. And the lesson we took from that was your leadership success, our leadership success in that moment is not just what you do. It is what your audience believes you'll do next. It is what you're communicating that you will do in the future because your stakeholders.

your audiences, the people around you, they're anticipating moves ahead. And as you build your leadership skills and build the organizations that you're part of, people begin to play out scenarios, right? They begin to say, how are they going to respond? If they respond negatively, are they gonna negatively impact our business? So we have to then mitigate that plan by getting another anesthesia group in here, getting somebody I know and trust who can cover it right away in case there's an emotional reaction.

And what we really did not, and this was one of the key lessons, we pushed the change button too far. We pulled the lever too much. And we were talking so much about CRNA practice. We ended up costing a CRNA only contract. Let that sink in for a moment. We were so passionate about it that we didn't see our job is not just to advocate for our profession.

Our job is to solve the problem for our client. And we can do that in a way that's consistent with our values, right? But we need to solve the problem for the client. That's the value proposition. We didn't realize that at that point. We were not a mature organization, right? You need to take that value proposition and need to be communicating it clearly and regularly, okay? One of the key takeaways from this specific example, this is a real story. Like this is not a made up theoretical.

Right? We got the contract in a period of extreme disruption. We thought we were the heroes of the story, so to speak. We got, I don't think it was arrogance. We just didn't have the vision to see what our client really needed. And it ended up costing us a lot. And our leadership had to grow because of that. And this is a case of business leadership, right? So you need to remember, here's the point. It's not just what you do now.

It's what your audience believes next because as we started out saying, leadership is not just a title. It's words and actions that have impact. And typically.

When we say these sorts of phrases, it's words and actions that have impact. We're thinking about the inspirational. And I start our discussion today with this example of loss because they are always having an impact. Whether you're speaking or not, you are impacting the people around you and you need to remember that.

So the next example of leadership, okay, and this is more than just being a CRNA, leadership as scale, not just talent, okay? So we need to talk about this, this one leader model that couldn't scale, because this is often where, as I've grown, and I interact with CRNAs across the country now, and frankly, anesthesiologists as well, I see a lot of leaders who are good at solving problems, and this is a very, very good thing, okay? But as our community,

matures and evolves and gets into different layers of leadership, we need to think about scale. Now at that exact hospital, okay, we're gonna use this hospital a lot. We lost that contract, okay? We actually picked up a small hospital right outside the city. And so we actually just transferred a lot of the staff, maybe 60, 70%. You go through this thing called transition loss, not everyone's gonna stick around, it's understandable. And we went there for three or four months.

And eventually, and this is where, again, knowing the details of the business helps, the payer mix was exactly what we said it was, and it was exactly what the hospital did not realize it was. They misrepresented the payer mix to that MD group, and that MD group called us back. I'm not going to fill in all the details of the story, but eventually we got asked to come back to the hospital. And because of thinking long-term value, not just short-term hurt in our ego, we said, you know what, we can figure out a way, we can figure out terms to come back.

And so this gentleman, Ali Bighai, who's a friend and a business partner, he's the former president, as I was talking about, he began to solve all the problems. He was there every day. He was hands on ground, hands in the problems themselves, but feet on the ground, so to speak. And the problem was we wanted to be more diverse than a single hospital. That's pretty low leverage, right? In terms of the overall market, in terms of payer negotiation, hospital negotiation, and so on.

pays to have your feet in more than one basket, so to speak. And as Ali tried to go off and grow the business or go off and just have a clinical life outside of one hospital, every time he was gone, all of these problems blew up. Cases got canceled more frequently. frankly, went up because we had some inexperienced CRNAs who didn't have the clinical experience to know how to navigate clinical problems. And when they don't know how to navigate them,

They don't know how to communicate with surgeons, problems occur, and that surgeon variably says, well, if this was an anesthesiologist, and now he's a CRNA, he's a CRNA, he's a CRNA, and he was able to navigate that a lot over time. The problem was, anytime he left, as I said, he couldn't figure, the place went, you know, went poorly, right? So over time, we realized, okay, we need to grow our leadership now. Our leadership has to go from solving individual problems

to building in other leaders. And at the same time, while this was occurring, that small hospital that I mentioned, that small hospital outside the Valley, great scope of practice. We've had that relationship in place for many, many years. There was an individual, his name's Michael Moreau, pretty new CRNA. He left a kind of a toxic practice where they over-promised and under-delivered. He joined our team and he began to grow. And we realized like, this is a leader. We need to make room for this guy, right?

And this is a common pitfall for a lot of leaders. A lot of leaders try to hold everything very close. I need to be the one on the ground fixing these problems, right? They're not thinking about how can I create a system? How can I create coaching, mentorship, develop these people so they can begin to solve the problems? And that's how organizations with good values can grow. And so in this moment, every time Ali left, problems ensued, we said, okay, let's get Michael in there.

His name's Michael Morel. Michael gets in there. And frankly, in the market, this hospital began to develop a poor reputation from an anesthesia point of view because it was so chaotic and Ali had so many different responsibilities. He was stretched too far. So we installed Michael. Michael took to it very quickly. He began to build credibility with surgeons, with medical exec. We made sure this time around we had

friendly allied physicians to make sure that they could advocate for us as well. And Michael is a generally buoyant, positive personality. And to boot, he's an incredibly skilled CRNA. Michael effectively rehabbed that organization over two to three years, where now the surgeons feel like that place doesn't run without him. And Ali began to move on to other problems to develop other leaders. That's the story. Here's the point.

Great leaders don't just solve problems, right? They build people who solve problems. They build systems that solve problems. You can see on the slide, this is Michael Moreau. He is an equity holder and that we have a leadership pathway in the organization and so on and so forth. He's really, he's on his way to becoming even more senior leader. Well, Michael will now be the one overseeing multiple other sites and

In this model, you're not solving every specific issue. You're coaching, you're mentoring, you're setting a tone and communicating direction and pulling institutional learning so that all of those chiefs here and all of those medical directors can solve the local problems. Right. And it's all in service of this idea again, that leadership is action and words that have an impact. This idea of we got into the hospital and we got fired.

And that's because we didn't communicate well enough around what our actual plans were and what we were open to. And now we're applying that idea to, we need to not just solve problems, but we need to empower others. We need to coach them and use our words and begin to be very good listeners, very good diagnosers of problems. And that's how we grow our leadership. That's how we grow the impact of the organization. And if you're like me and you want to do your best in life,

You want to be aligned with an organization that has that same values. It's not just about money. It is about impact. That's leadership.

Always tell your story, but tell it right. This is about compensation and perception and presence. Also a story about anesthesia subsidies. And if you're wondering why I put a picture of eggs on the screen, it's because eggs are very expensive. And that's what anesthesia subsidies have become. Same hospital.

orthopedic hospital. Years have gone by at this point. The anesthesia market is changing rapidly. We are providing the top notch service. Michael is the chief CRNA at this organization providing top notch surgeons, excuse me, top notch service. We're doing the flip rooms. Now flip rooms, you know, to many people on the room meet, I might get a little more of a break in between my cases, right? Not usually much.

but maybe a little more flip rooms from an anesthesia revenue point of view or an economic point of view means your revenue is cut in half, right? Somewhere around half, maybe 60%. And when you're already living in an environment where the fees for services are somewhere between 40 to 70 % of the actual cost of doing business, this is a compounding problem. Now I'm a fairly experienced leader at this point in the relationship.

I thought it was my job to communicate, hey, I just want to signal early on, like the market is crazy. Here's the data, right? On what this market really looks like. I'm doing all the things, frankly, I've been a CRNA since 2012. I've been in leadership for a lot of those years and I'm doing all the things that I tell other people to do. And I think I'm doing the right thing. I'm like, hey, Eric, this is the CEO at this point.

You know, the market is absolutely crazy right now. So I'm at Lake Tahoe in the state of California, vacationing with my family. go every two years, we vacation as a giant family. It's kind of a special thing. And I think I'm doing the right thing. And I got a text from Ali, one of my key business partners. And we actually near right near the water,

And I'm driving back to the hotel to get something. And he says, did you see the email from Eric? And I'm thinking, gosh, really never am on vacation. And I thought it be, you know, something about, I don't know, clinical quality or request a meeting or something like that. And what the email said was, thank you for your service over the years. Your contract will not be renewed. And I was like, no, are you kidding me? Like, this can't be real.

Right? Like this is no, this can't be real. I'm like, it took a while to hit me because no, mean, I've told them that, you know, I haven't actually asked for any more money. I've definitely, you know, intimated or signaled that we're going to need something or at least you need to change something operationally. I was wrong. I was wrong. I lost. Right. We got fired. I remember going back to the hotel lobby.

And say, was like, you gotta be kidding me. Like, what are you talking about? Are you sure about this? And they're like, yeah, we're sure. We've asked you to lower your subsidy three and four times. You're not willing to do it. And I said, we're not, are you reading the news? I was very upset. Are you reading the news? And they're like, yes, but we're partnering with someone now who feels like they can do this for a lower subsidy and do it effectively. Thank you for your service over the years, but ultimately this is just a business decision. That's the story.

This is your point, okay? You need to tell your story like a leader or someone else will tell it for you. Now in these circles, you will, in these lectures, these discussions, you'll often hear, you need to tell your story or someone else will tell it for you, right? You need to be in the room or you're not part of the deal, right? We were alluding to that earlier. It's an aphorism, it's a colloquialism, it's a common saying, and it's true. But when you're increasing your leadership ability,

You need to not just tell your story. You need to tell your story like a leader. And as I reflected back on that situation, I realized I may have been saying the right thing, but I was not saying it the right way. And my lesson there was that presence, executive presence, matters. Your language matters. Communicating authentically like a leader can open doors. But what I really learned there,

Was that even with the right message?

Even with the right message, if it's framed poorly, can close them. A lot of people ask me, you hey, what books have you read on leadership? Like, we're looking for a playbook, they're looking for the manual. And I will tell them the two most important books that I've read in my career are as follows. Okay, the first one is Crucial Conversations. And I'll share why later. It's a great book. But in regard to this, the second one is

the four agreements. And one of those agreements, it's a spiritual book. One of those agreements is words have the power to create or destroy. And as I think about leaders and trying to empower them and equip them, they need generally to think more about the impact their words have. And in this specific instance where the CEO effectively told me, I don't believe you, you showed me the data, I still don't believe you.

You guys do a great job every day and you're very hard to replace, but I don't believe you. Looking back on what I could have done better, not wrong or right. We're not in the world of wrong or right here. Leadership and business, it's not about wrong or right. It's about effective outcomes. ⁓ And I learned that I framed the message poorly and that door closed.

I'll share with you now what occurred and I calmed down. I was in the lobby of that hotel on vacation with my family and I calmed down and I began to think long-term. I began to think about lifetime value. I began to think I may run into this person at another point, even though I want to do everything in my power, the pro-Magnon man in me wanted to do everything in my power to get back and fight back and do everything I could to get this guy fired in the future. I said, you know what? I understand.

Yeah, you know, obviously, we're a little sad, but, you know, I understand you got to make this decision. We'll make, we'll try to do everything we can to make sure it's a successful transition for you. And then we ended the call and two months went by and they brought in a large private equity organization and you know, their business models, they effectively undercut groups, medium sized groups like ours. And they met with us and they said, would you like to work for us? And we said,

We'd help you with the transition, we'll be professional, but that's never going to happen. Right? Absolutely not interested. I said, okay. And a little more time went by. And because again, speaking back to the lesson learned from the first example, we now have added physicians as members of the organization, anesthesiologists who are very good and allied with our way of doing business as far as anesthesia models go.

So our physician is on the credentialing committee and he says, no one's getting prudentialed here. Like they're on a clock. We're not, you know, if if the date was December 1st, we're not going to be here December 2nd. We, you know, there are, we have to go and get other business now. And so we, you know, we realized, well, this is a new dynamic. I remember what I said about, you know, framing things in the right way. And I ended that call.

in the right way in that hotel lobby and said, you know what, we'll try to make a successful transition. I'm trying to rescue the relationship at this point. Two months later, I get a phone call. I was in this exact room, actually, when I got this phone call. And we got this phone call. And he's like, you know what? We've reconsidered. is, you know, sometimes you make calls that don't play out the way you anticipate. And I'm keeping, obviously, names anonymous for a reason.

But he said, can we explore keeping your team here? And my instinct here was to drop the brick on the gas pedal here, right? That's that's the Cro-Magnon man instinct, right? The blood rushes to your skeletal muscles and instead of up here, your prefrontal cortex. And I, know, but I was like, okay, how do we get this to the best possible outcome? Because leadership is not just about winning. Okay. That's a childish way to think. Leadership is about how do I get to the best possible outcome?

for the people that I am accountable to, the members of our group, the everyday CRNA, the people that we're passionate about serving and protecting, and frankly, the anesthesiologists as well. All of these people and their families are depending on the decisions that we make as a leadership team now. So I said, you know, to this individual, the CEO, said, obviously, you know, this is a disrupted situation. Many people have made other plans already. We're less than two months away. This is gonna be a challenge.

But ultimately all problems are solvable. Here's how we can do it. And we took about a week or two weeks and we eventually came back and ironic and we ended up with a long-term agreement to make sure our interests were reasonably protected. There's a lot of conversations that went into those deals, but the leadership of our organization then became more mature. We advanced from, hey, we're here to do things our way to, hey, we have to figure out how to solve your problem.

in a financially viable way that makes sense from our values and ethics. And that's what we did. In that moment, again, it was the action of, I put the screws to this guy and charge him like crazy? Or do we take a more reasonable position, make sure our value is protected, make sure our long-term interests are protected, but try to find the win here? And make sure that message is communicated in a way that says, we're not a mom and pop shop.

We're a senior team of leaders now navigating a very difficult market. Leadership is action and words that have impact. And now, coming full circle, that hospital is a great place to work. It's probably one of our most popular sites across the entire company.

Leadership has a lot to do with accountability and accountability builds trust. Okay.

You're seeing a picture of someone who looks very stressed. And at one point within our leadership organization, we had a major problem. And that was our leadership became bifurcated, right? We had effectively, actually it was more like trifurcated because we were effectively running three different companies. We were not running one unified organization, capturing synergies, right? That's the buzzword, but effectively being efficient. We had three little chieftains and

I remember right where I was, because I was very stressed because I was evolving into the role that I have now. And I'll certainly talk about, as Danny said earlier, what development officers do or business development people do. I was, began to wrap my head around the essential element of any business or any nonprofit business as well, which is the P &L, the profit and loss. We're extending all this risk, all this money, all this effort. Are we getting a return? That's what everyone wants. And I realized we were not.

getting that return. We were spending an awful lot of money because one leader had a long-term business strategy that said, we're going to effectively invest, invest, invest, invest, grow so quickly. It might be very hard to return, get a return initially, but long-term it's going to work out. And I began to realize that I'm not a patient person. This individual is, okay? And

You know, we had a serious disagreement. His name's Randy Quinn. I don't think he would mind if I shared it. And as I began to realize this, I came back to the city of Phoenix. had spent some time back East due to a personal issue and now I'm back West. So it was in this transition mode. I was tired. I was stressed. I came back to the city of Phoenix. I got to a hotel lobby, just like the one you see here, right downtown Phoenix. And we began to talk about this. And, you know, this was one of the times where I definitely used a lot of expletives on the meeting.

And this is supposed to be my evolved state, but I was livid that this was going on. And I was trying to hold my business partner, hold our team, our entire team accountable. This was not the right way to handle it. So I stepped back from that phone call. I eventually called him and apologized for my behavior on that call. And eventually we came because we wanted the same thing.

we came to an agreement on how we would navigate this strategy, right? To manage the growth effectively. So again, so we could effectively pay our bills. And what eventually happened is we began to become, I hate to say this word, we began to become a little bit more corporate. And what that really means is we began to have clear roles and responsibilities. And we are not afraid to hold ourselves accountable to those roles and responsibilities.

At the same time, and this is the key, if you're in a department leader or you wanna become a department leader, whether it's internal, external, or frankly at your church or your synagogue or whatever it is, right? There's this tendency in every human organization in my experience to say, this is my job, I only wanna do as much as I have to do and I wanna get home. And that's fine, that's human nature, right? But sometimes we see problems and we say, that's not my job.

And I bring this up now because when things get, the reason there's a negative correlation with corporate is because it's ineffective, right? It's, you know, it's hard to navigate that bureaucracy. It's annoying, right? And as an entrepreneur, it is annoying to me, but there's a time and a place. So not only did we install officers and with distinct responsibilities who were directly responsible individuals, okay? At the end of the day, someone's got to be held accountable, okay?

We also adopted this team of teams culture. This is, I steal ideas from everywhere. This is Stanley McChrystal's idea. Now you may not know who Stanley McChrystal is, but he's an American general. And when he was fighting in the Middle East and you know, to put it candidly, we were losing. And that was because they're a corporation, just like any other in many ways. And they were too siloed. They said, that's not my job. And so they began to adopt this team of teams culture. And team of teams simply means

being flexible between roles, you need a directly responsible individual, that's for sure. But when you see a problem over here, just because it's not your department, doesn't mean you can't solve it. And just like with the business partner that I was working with, or that business situation rather, it was his problem to solve now, but he began to draw other resources, team of teams approach, and all of a sudden we turned that back around to profitability, and we did it in a highly functioning way.

because we were accountable to one another and we were paying attention to results. If you read a five dysfunctional team, the top of that pyramid is inattention to results. The bottom one is trust. And when you are able to hold one another accountable and you're a leader and you hold your team accountable and they hold you accountable, that is where you begin to build an effective team. That is a key part.

of your effective leadership. And this was a specific example on how to do it. And I know a lot of CRNA leaders get uncomfortable with this. It's not easy to do. But it is not about blame. It's not about I'm the boss and you're my subservient or you report to me. It's about clarity. It's about saying, hey, I noticed this was our goal. This is where we're at. Help me understand how we can get here.

or help me understand the things that I can help solve to make it easier to get here towards that goal. And you can see the words on the screen, right? Without accountability, even talented teams fall apart, but with it, they fly. Okay, and yes, this is a reference to the Philadelphia Eagles being not so good last year and this year winning the Super Bowl. Okay, I should probably put an eagle on the slide instead. But the overall point is again, leadership is action and words.

that have impact. Two more examples of leadership in anesthesia now. We talk about data a lot in our world, Got a lot of great PhDs that know much more about data than I do. I know enough to be dangerous. But sometimes data gets used against you in ways you would not anticipate. There was a hospital where we shared a proformo, and a proformo is just a projection.

Right? It's a business projection. Say, hey, this is what we expect to earn. This is when, this is related to cashflow timing, when we expect to earn it. This is what we expect to spend. This is where we will get to profitability. And this is where we expect to use that revenue, invest back into the business, so on and so forth. And it was in a period of my leadership where transparency was kind of a buzzword. And I was experimenting with how this could work in the real world. And I sent a pro forma to a hospital, a proposal.

which was part of a proposal. And I said, hey, these are our expenses. This is why you need to pay us an awful lot of money, in other words. And we had administrative costs, we had billing costs, we had some sort of operating margin, we had expenses, which is usually 80, somewhere between 85 to 95, depending on the situation, percent. And this is a big number, right? This is like a five or $6 million contract. And let's just say the administration is about 10%, which is a reasonable number. And it's like five, $600,000.

I thought this was no big deal. I'd use this in other facilities successfully. And so I thought this was okay. So I signed the contract, services go along, year two comes around, and they begin to look at my numbers. And they said, Joe, do you really need half a million dollars to run this hospital? Right? I mean, that seems like an awful lot. And I realized in that moment, I was like, how, where is he quoting this from? I was like,

He's using what I sent him. He's using the exact information I was trying to be a good transparent partner and he's using it against me. And then I began to try to explain there's all sorts of costs that we have to account for. We pay everyone's credentialing fees. There's banking costs, there's RCM costs. Grandma does not always pay her bill. And frankly, all of expense projections you see in that data, once I realized he had gotten it from me,

All of those expense projections are off considerably by double digit percentages. Right. But he didn't believe me. And eventually we got around to a positive solve. But the point is this, you need as a leader, as a leader in an organization or just as an individual, you need to control the data or it will control the narrative for you. And this is the real lesson behind this.

Sharing the data, data is destiny, right? In God we trust all others bring data. These are the aphorisms to say, hey, we need to at least have our heads around data. But if you're growing in your leadership, the next thing you need to realize is this, share what builds trust, not what builds leverage against you. I have a rule in operating with anyone, which is you should not ever expect anyone to go against their interests.

This is unwise. Don't ask people to do things that are directly against their interests, unless they're your personal friend, right? And they're going to do you a favor. In fact, a good definition of a friend is someone who puts your interests ahead of their own, right? When you love someone more than you love yourself, this is a really good definition of a true friend. And you can have friends in business, definitely, but until you know that, don't share anything, especially data that can and will be used against you.

in the future. And that was the real lesson there. And I've taken that leadership lesson with me now, where I say, it's important to be appropriately transparent, but it's also okay to have privacy and boundaries when you're leading an organization. Because then it goes back to, again, who are you really responsible for as a leader? And this is the magic of business leadership, association leadership. When you think, when you're lonely, because leadership is a very lonely thing, you need to realize,

Your decisions, your words, your actions impact far more than just you, right? That is the sacrifice you choose to make as a leader. It's not about just you. It's not even about just your members, right? It is about your members and their families and the people who are counting on their families and this relative stability that you can afford them. That is what you should be striving for. So these are the key lessons that I've taken over the past few years.

And I wanted to pull them from very specific examples, real world examples. But there are some basics that every leader should know, some basic tools that you should have.

These are some of the problems that we face early on as an organization. Our early leadership was based on, we all showed up at the same time. We're all equal partners. And then we had to learn equal doesn't mean the same. ⁓ You can be equally valued. It doesn't mean you're contributing the same thing in the same way, but you can be equally valued. And there's a lot of different ways to measure that value. We didn't really understand financial models.

There is one point, there's so many lessons from the past 10 years or so, we didn't understand those financial models to the point where we almost drove our company into the ground. We had no idea what this little phrase meant, cash flow timing. Okay? Our meetings were inefficient, right? That's a drag on your personal life, it's a drag on your energy. And our communication was either too sparse or too complex. And here's how we overcame these things. And these are ideas you can take with you.

as you continue to learn and grow as a person and a leader, you need to know about governance. Who does what? How are they responsible? Eventually we went away from a kind of a regional, hey, where do you live? That's the area where you'll control to more of a, can we align people's strengths and talents to what they and what they actually want to do to their title and role in the organization?

And this makes a lot of sense, especially as kind of founder owned or founder run organizations where you have original people who still running the organization. That's not overly common. know, most of the anesthesia companies you know today, most of the hospitals you work for and will work in, right? The people who started them are probably not there. It's either evolved and been around for a long time or it's been sold or something like that. But regardless, the principle is you want a title and a role which aligns to your strengths.

Otherwise it's gonna be a struggle. That doesn't mean you can't be challenged and adapt, because that's key to survival, but it does mean generally speaking, try to align with your strengths and try to make your governance, how you make decisions align with that as well. That is how I ended up with Chief Development Officer as a title, because I like to build things and I'm very comfortable being out there. And that's part of what Chief Development Officer, Chief Growth Officer, Chief...

know, vice president of business development, these are all very similar things, right? The key is you're trying to bring growth into the organization, the right type of growth, not just any growth. And for me, that's on both the provider side as well as the facility side, the client side. A lot of these discussions about leadership or business or what have you, we talk about billing. I'm not an expert in billing. I would imagine maybe both Tracy and Drew from our earlier discussion know more about it than I do.

But I do have a reasonable sense of finance. And if you're leading in this industry, in this specialty, you should have an understanding that number one, like I said before, the fees for services are not sufficient for the actual cost of services, generally speaking. There are some exceptions by volume, that sort of thing. But the most of the areas where we work, that principle is true. And then when it comes to subsidies, there's really two buckets. And this is what most people

don't have any idea about, right? Which are, most subsidies are one of two things. They're either flat, i.e. you show up, you get this amount, and that can be broken up on a daily, quarterly, monthly, yearly basis, and the risks and benefits shuffle back and forth depending on the details. Much of leadership is mitigating risk, okay? And that's where you begin to mitigate how these financial models are structured. The other main bucket you should at least know about is this idea of a dynamic

subsidy as my characterization. there's many words used for a dynamic subsidy, whether it's collections guarantee, revenue guarantee, revenue threshold, cost plus. All of these reflect somewhat different arrangements. But the key to all of them is that the financial payment from the facility changes on a month-to-month basis or changes on a year-to-year basis based on

The math, right? It might be the same month to month, but eventually you're going to change it because of the math involved. Again, flat or dynamic. Those are the two main types of financial support. Two other key things you should have in your bucket. Learn how to run a meeting. Start on time, run it efficiently. I have a saying, I like my sayings, no agenda, no attenda. I.E. if there's no agenda, I'm not showing up. Right? If we want to hang out, I'll do it after work.

But I've got a lot to do. I will make sure I have a lot to do. So if there's no meeting, there's another clear start, middle and end, I probably will not be there. I'm just doing a little water cooler talk, I am a human being. And finally, and this is probably the single most important aspect, we could do the entire discussion today based on this, which is communication. Adopt a habit of relentless and simplified communication. If you're a leader,

and you are not absolutely sick of hearing yourself say something over and over again, I almost certainly you have not communicated enough. Our biggest lesson when we took on a large academic medical center, I would share something and I assumed everyone would listen. Not an unreasonable assumption. What I didn't realize is it about 14,000 different friction points in any given communication. People's jobs are busy. They're stressed out that day. They didn't sleep enough.

All these things make whatever I'm saying not reach into their mind. So we actually have good back and forth communication. As a leader, you will be communicating all the time. That is the expectation. That is the baseline. Do not be frustrated when you have to communicate a lot. That doesn't mean that principle only goes so far. It doesn't mean people shouldn't be listening to you and you're just repeating yourself ad nauseum. But at every opportunity,

small interactions, big meeting, you should be projecting forth that vision of what you want to happen. That is your job as a leader. If you're not doing it, you're not doing your job. And that's what we didn't do in that first example. I'm gonna close with this idea. There's a lot of talk about how do we get started. I got out of Thomas Jefferson University in 2012. I had approximately $180,000 worth of debt. I had $20,000 worth of.

credit card debt, we moved across the country into an apartment or a small home that we had never seen before. And all of that stuff was happening. And those are all a lot of reasons not to get involved in my professional community. And then I got a phone call. And I was in a small room, just like this, probably not as nice. We had just gotten to the city of Phoenix. was actually a city called Surprise outside that. It's all, called the Valley. That's what we refer to it as.

And it was from Jose Ortiz. And he said, hey, man, I hear you're in state. I know you were involved as a student then, near St. Ecisra resident now. And I'd really like you to show up at this meeting. I said, man, like, I haven't even passed boards, man. Like, I'm just, figuring this out. And, you know, like, this is one time where I was like, can I just, can I live a little bit? And Jose, he said it to me. He said, man, this organization,

needs you. We need people like you more than you need it. We need you to step up and serve. Can you just show up and be here? And I was like, you know what? That's, that's, he's right. I need to show up. I need to serve my community and show. showed up despite my wife's miscrease in this and my wife's very supportive, but there was a lot going on. She's like, really? And I was like, yes, I have it. She was like, okay. She's been ultra supportive all these years. And at that meeting,

that I went to, I actually met, I sat next to trusted, beloved business partners, both the originals, there's more involved now, but Randy Quinn, he was immediately to my right, we had our first disagreement at that meeting, and Ali Begai was off to my left at this giant boardroom table, and we began to develop the trusted relationship where you can work through problems, when you can align on a greater goal, when you can develop your leadership skills together.

That's where it started for me. The point is leadership starts when you show up and before you are ready. You're not going to be ready. You need to jump in. Leadership is for the willing. Leadership is not reserved for the chosen few. It's for people who are willing to stand up. The picture you see is a guy named Cody Burch. He's actually a former CRNA with a history of addiction.

And as you can see, he's trying to take good care of himself now in his own way. He is a leader in his own life. And so that is what I leave you with. leadership is not something that not everyone can do. Okay. It is something that if you want to and you're willing and you're willing to take the words and the actions under control in your life, that is when you become a leader.

So that is what I have for you today. ⁓ Hopefully these stories again from the hospital, whether we lost our contract, whether we said the, we had the right message, but the wrong framing, right? We didn't know how to develop our leadership pipeline. And now that is part and parcel of what we're doing every day. And just those basics of how do we govern, who makes decisions? How do we run meetings? How do we communicate? And what is our expectation in regard to communicating?

That's what being a leader is about. I hope some of these things are helpful.

Thank you, Dr. Rodriguez. I appreciate that lecture. Yeah, I mean, that just kind of scratches the surface for all that we should be grateful for, for the work that you do. ⁓ The question that I wrote down, and you kind of started to infer some of these things, but my question was,

What is the toolkit you use to take that potential and transform it into being an effective leader? You mentioned crucial conversations. You mentioned the four agreements. Did you want to go into a little bit more depth about those two books or are there other things the working geniuses or what kind of tool kits do you use to try to help them fulfill that potential? Tool kits is the right word. Tool kits, framework. And I think a lot about frameworks, about how we think because when you get a

framework and you have those tools, you can apply it in a million different ways. So in our organization, it's really three things, right? I mentioned two and I mentioned one very briefly, ⁓ crucial conversations, the four agreements, which is more on the personal side, and then five dysfunctions of a team. As far as how do we want to operate at scale and get to results, right? And with that leader, that leadership specifically, I think it's realizing two things. The first is striving is a very human thing. Most people want to strive.

Your job as leader is to create the pathway for them to do it, which probably means you have to let go of control and get out of the way, which is what we have to do in that situation. And then with the convert, the communication aspect, it's being very clear on what you are trying to communicate and not trying to communicate. Pro tip, everyone assumes the worst about you. So you have to actively say, I am not trying to interfere with your life, Michael. I am trying to make sure you have a place to grow. You seem like a guy who wants to grow. And immediately then,

Yes, I do. So don't rely on implications or inferences, but to be actively not just saying what you want to say, but also saying what you don't want to say. Absolutely. Yeah. And that's clarity. Right. Most people, I think, in most people with leadership on any aspect is the amount of disagreement you start with is here. You think that person's a jerk. I can't stand that person. But then you get to know him. And your job as a leader is to clarify down.

the narrow path of disagreement, and that is the narrow path of success, right? And it's a narrow path. And that's what I try to emphasize to people. Don't make assumptions, right? You don't know what's going on in their life. They may have just been tired. Maybe they're just a jerk. Maybe their dad's reading like garbage as a kid. It doesn't matter. Your goal is to get to that goal. All that other stuff is noise. This is the goal. That's how you have to approach it.

Love it. Love it. And that takes work. That takes emotional energy. That takes skill. Like you talked about simplifying conversation. I can't tell you how many times like you write an email and it just isn't simple enough. And so you take another stab at it. You take another. I mean, maybe you use chat GPT or other things to to to make that more effective. But yeah, that really good communication. Somebody is curious in the chat about why you use the different rooms in your presentation.

Yeah, can you describe the room or space where certain conversations took place? like which story he's referring to, so to speak. Look, these took places in a mix of board rooms, so to speak, or an office at a hospital, or frankly, in this room where I'm literally sitting right now. I think, yeah, mean, look, we had a saying, if you're not at the table, you're on the menu. And it takes a long time to get in the room.

Right. And what I'm trying to share with folks now is I've been in these rooms for a while and now I'm learning, I'm making other mistakes and now I'm trying to share those as well.

Well, and that's what I think a good leader does or somebody who's productive does. I mean, that's what all of our NARs are doing every single day in clinicals, right? They're making mistakes and they're doing their best to try to learn from those mistakes. And that shouldn't stop once you cross the stage or once you pass the national certification exam. That's right. Keep learning from those mistakes. So well, Dr. Rodriguez, we've reached the end of your time. I can't thank you enough for your support for Kana, but also sharing your experience to try to lift up the profession as a whole.

Thanks for all the good work that you do. And next time you're up in Tahoe, let me know. I'll take you out to Cave Rock. It's a pretty cool place, let me tell you. Very good. All right, everybody. Have a lovely day. Take care.