Episode 82:
Children Don’t Vote
Sandra Fenwick, President and CEO, Boston Children’s Hospital
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In this episode of Fireside Chat, we sit down with Sandra Fenwick, President and CEO, Boston Children’s Hospital, to talk about the high level of Medicaid patients in children’s hospitals and the need for more governmental support. We also discussed major trends in children’s hospitals and outlined the successes and challenges that are inherent in leading a children’s hospital.

Sandra L. Fenwick is the Chief Executive Officer of Boston Children’s Hospital, where she leads a team of 20,000 people dedicated to improving and advancing child health through their life-changing work in clinical care, biomedical research, medical education, and community engagement. Ms. Fenwick is a leading advocate for a recommitment to investing in children — especially pediatric health care — in the face of growing threats to our children’s health and well-being. Read more


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Sandra Fenwick  0:03  

Children don’t vote, so investing in children is something that, I think, has to be on the agenda of our national policy, but also at the state level, and of course at our local levels.


Gary Bisbee  0:15  

That was Sandra Fenwick, president and CEO Boston Children’s Hospital, speaking about the high level of Medicaid patients in children’s hospitals and the need for more governmental support. We built on Sandy’s observation with the title of this episode. I’m Gary Bisbee and this is Fireside Chat. She discussed the major trends in children’s hospitals and noted that only 35 remained freestanding. She outlined the successes and challenges that are inherent in leading children’s hospitals. Sandy is retiring in March and she shared stories of leadership lessons that she had learned through the years. In her earlier days, she was frequently the only woman in the room and she developed thoughtful strategies for turning that into an advantage. Sandy distilled her lessons in being a top leader into four buckets that are worth listening to and adopting. She is prepared for retirement as she led Boston Children’s in a thoughtful and well organized way. She shared what she’s looking forward to and what she will not miss. I’m delighted to welcome Sandra Fenwick to the microphone.


Well, good morning, Sandy, and welcome.


Sandra Fenwick  1:29  

Thank you, Gary. Pleasure to be here.


Gary Bisbee  1:31  

Well we’re pleased to have you at this microphone. Thinking about your background, and we do like to start learning a bit about our guests and their background, you grew up in New England and have most of your professional career has been in New England, grew up, I believe, in New Britain, Connecticut. What was life like growing up in New Britain, Sandy?


Sandra Fenwick  1:49  

Well, it was actually, back then, it was a great place to grow up. I grew up with somewhat humble beginnings. My grandparents were immigrants from Slovakia, all four of them. My parents did not go to college, but they believed deeply in family values, love, spiritual grounding, hard work, and most importantly, service to others. So we had a wonderful life. 


Gary Bisbee  2:13  

So were you the first college grad then in your family? 


Sandra Fenwick  2:17  

I was and then my three siblings went and all of us have gone on to get higher degrees as well. So a great grounding.


Gary Bisbee  2:24  

Well, you strayed far from New England going to get your masters at University of Texas. What was that decision like?


Sandra Fenwick  2:31  

Well, that was a couple of steps later. I went to college in Boston and took my first job at Harvard School of Public Health. And from there, actually was asked to go to Saudi Arabia. And so I spent the first two months in Saudi Arabia on a research project in one of the hospitals in the eastern province. And two months into this, the department chair asked me if I would stay on for an additional two years and run the program. So I did that, which was a pivotal time in my life and met my husband there. And the two of us then came back to the US and we ended up in Texas. So that was a long way around to get to Texas.


Gary Bisbee  3:12  

Quite a loop. Well, let’s back up a bit. Where did the interest in healthcare come, Sandy?


Sandra Fenwick  3:16  

I had always thought I wanted to go to medical school or to get a PhD in science. I have always loved medicine, science. So I was pre-med/biology/chemistry and thought I was heading off to one of those graduate schools. And I took my first job and it was really that job that made me think you could really combine not only medicine and science in a healthcare setting, but it was really that opportunity in Saudi Arabia that made me say, “Wow! I have been given the opportunity to sort of be thrown in the deep end of managing this program.” And that’s when I said, “This is kind of where I think I belong – in management and leadership and the like.” And so that’s where it kind of all started. 


Gary Bisbee  4:02  

Well, the leadership question is a good one. Some people are, at least by my observation, what I would call natural leaders. That doesn’t mean they don’t study and improve, but they’re just good at it. Where do you fit on that spectrum, Sandy? You appear to me to be somebody that very easily moved into a leadership role. 


Sandra Fenwick  4:23  

I guess maybe a little bit of it is the way that I approach work. I take it extremely seriously. I’ve always had a desire to look around corners and think about what’s coming and how to position whatever the program or my institution for the future. And to not just be buffeted by change, but to really embrace it, to innovate, and to lead. And so those have been the way I’ve always worked. After my masters, in Texas, we moved back to Boston, and my first job at Beth Israel Hospital, at the time, within a year I was asked by the CEO, although we didn’t call ourselves those executive and corporate names back then, he asked me to take on a role as the first woman at Beth Israel in a senior leadership role. And what I realized is that I was sort of a pioneer because I was the only woman at the hospital. But I was also the first woman in academic medicine in Boston. And as I looked around the country and when I went to meetings with him, I realized I was really only a handful of women back then. This was 1977. So I basically just embraced that and just kept moving forward.


Gary Bisbee  5:36  

What did you like most about leadership?


Sandra Fenwick  5:39  

There are four things that define how I think about leadership. First, is having a passion for where I was and what I was doing and who I was working with and for. And so for me, it was always about making things better for patients. And so being a leader, it was always with that kind of North Star. Always thinking about whatever we do, let’s have the patient, and now at Children’s, it’s of patients and families. The second thing is taking risk – taking risk to go to Saudi Arabia, taking risks to take on that first role at Beth Israel, and then subsequently, each time I took on something new or was asked to take on something new or was sort of thrown into something, it was having the courage to try, to keep taking on one more thing, recognizing that there was a chance of failure, but just pushing through the barriers. The third thing is having vision – just what could be better? How do you look to innovate and to do something that does allow for either your institution or program whatever to lead. And last but not least, to do that all, I think about this is, not only what you do, but how you do it. And so for me, it is all about leading as a moral leader and leading with integrity with humility and respect and dignity. People look for competence, but I think they also really, really expect character. So those are the ways I’ve always thought about leadership.


Gary Bisbee  7:09  

Well you make the point that you were a pioneer from a gender standpoint as a woman in academic medicine and just generally, I would think, in the health system or hospital leadership. How did you handle that? There must have been a number of different challenges small and large as you worked your way through the career as a successful woman leader. How did you think about that?


Sandra Fenwick  7:34  

Well Gary, especially way back, I was probably the only woman in the room in medical staff meetings, in board meetings. I was asked to take positions outside the institution with organizations and the like. And many times I was the only woman. And so part of it was just how do you break through? How do you contribute? How do you listen? And then how do you engage? How do you have the courage to speak up? And how do you weather occasions when people are hurtful or really aren’t very respectful? And I think part of it is not letting it get to you and taking it really personally as a human, as a person. Sometimes it was out of complete ignorance and sometimes it was people’s own value systems. And so what I just felt is that you had to just keep plowing forward. You had to keep trying to figure out how you add value? How do you take the long view? How do you work in getting to know people in organizations and having those relationships at a very personal and human level that allows you then to develop those relationships that helped you get through some of those harder times?


Gary Bisbee  8:50  

In the 45 years or so since you started as a leader at Beth Israel, how much better are things now for women leaders or not? How have things changed is probably the better question?


Sandra Fenwick  9:04  

At the very beginning I found a group of women who had not yet even gotten to my level, and even women who were in healthcare but not necessarily in academic medical centers or hospitals, we started to try and figure out how we help each other. And so we decided that we were going to try and place the first woman as a CEO. And I had just had my first child. And I said, “I’m not quite ready, but I’m going to help.” And so we set out, in fact, to I think it was probably close to 1980/81, in that timeframe. We were written up by the New York Times as a group that really pushed that boundary over the edge and we were able to place two CEOs in, they’ve turned out to be community hospitals, not academic medical centers. And that was the beginning. And we just have taken off in Boston now among the academic medical centers, there’s five of us. So we’ve made some huge progress. Same is true around the country. And I think we are now on boards, increasingly, both nonprofit as well as public companies. But there’s still a long way to go.


Gary Bisbee  10:15  

Any advice you’d give our younger listeners who are up-and-coming women leaders?


Sandra Fenwick  10:21  

I was on a panel yesterday, and I heard one of the most thoughtful things that someone said, and that is, “Don’t follow the money, follow the opportunity.” People sometimes say, “Oh, I’ve got this great opportunity for a new job. It’s going to pay me double, or it’s got a new title.” It’s all about doors that can be opened. What you can learn. Who you can meet. How you can contribute. How you can be more visible and viewed by others as someone who might be tapped for something you didn’t even know was potentially there. And so I just think that watching all of those things that you can position yourself, managing your career in that regard, as opposed to, I’m going to stay in one place and I’m going to demand because I work hard and I give it my all, and I’m going to get a promotion, I’m gonna get more money, I’m gonna get more opportunity. But it’s also watching all of those pieces and how they fit together.


Gary Bisbee  11:19  

Love that advice. Terrific. Well, let’s go back to your career. So after 20 some years at Beth Israel, you became the CEO at Boston Children’s. What was the set of decisions that you pursued to accept that appointment, Sandy?


Sandra Fenwick  11:36  

I had just led to the merger of Beth Israel and Deaconess to form the other major system in Massachusetts called CareGroup. And it was a wonderful time. It was an amazing time in the, now 20 plus years ago. And I went up to corporate and was asked by the new CEO to develop the blueprint for the whole system. And it was a wonderful time, but I really missed being inside the hospital. And so that’s when I decided I really wanted to get back into the hospital setting. And there was a wonderful opportunity at Boston Children’s, so I took actually a lateral move. I was a senior vice president for all of system development at CareGroup and I took an SVP job at Children’s for a lot of the same kinds of responsibilities. But five months after I got there, there was a major shake up here at the hospital. The board decided it needed new leadership at both the two top positions and I was asked by the board to take on the role as the Chief Operating Officer and they wanted to then search for a CEO. So for the first year I was there, I was COO and I was acting CEO. And then my CEO came a year later and we just partnered and had the most wonderful 13 years. But it was also the most challenging time, Gary, in the history of this hospital, up until recently with the pandemic and everything else that we’ve been living through. But we were hemorrhaging financially. We had a negative 26% operating margin. We were really eating our endowment. We had not made investments in this institution for years. And morale and alignment was not where it needed to be. So that was really the challenge that I took on first and then we did in partnership together.


Gary Bisbee  13:30  

Boston Children’s is always, or it seems like it has been for some time, ranked as number one among children’s hospitals. Why is that? What set of factors together allowed such a high ranking for Boston Children’s?


Sandra Fenwick  13:47  

Boston Children’s is an extraordinary place. And I honestly am so inspired every day, but also privileged to be part of this place. It is so broad and so deep across all of its four missions – care, research, education, and our commitment to community. And on the care side, we not only go very broad across all the specialties for children, but we also go extremely deep. Some of our divisions are bigger than the entire medical staff at some of the children’s hospitals. And so we have the ability to really subspecialize into areas that others really can’t even begin to touch. We have people who come here and stay for their whole careers and really explore and exploit the capabilities. The same is true in science where we have the largest pediatric research program in the world, the fifth largest recipient of NIH funds of all hospitals. So it’s a very big commitment. And the combination of care and science is, I think, what makes us unique, because we’re constantly looking to discover the basic understanding of biology of disease, and then translate that and increasingly move it as fast to patients as we can. And so, for instance, we were the first place to actually initiate a gene therapy trial for sickle cell disease. And, while there’s always challenges and there’s always risk involved with all of that, pushing the boundary so that we basically say, “We make the impossible possible.” That’s a belief and our motto is, “Until every child is well.” So we put all that toward really being the destination for children and hopefully, we’ll continue to be the number one children’s hospital.


Gary Bisbee  15:42  

What are some of the underlying relationships – relationship to Harvard, financially payer mix? How would you describe Boston Children’s from those standpoints, Sandy?


Sandra Fenwick  15:52  

We are the principal teaching hospital of Harvard Medical School. And so for the most part, all of the medical students rotate here. We have our own residency and fellowship program which trains both for people based here as well as those who rotate from all the other adult hospitals in the Harvard system and even other medical schools. We train well over 1,000 students a year. So it’s a very large committed program. We have about 415 beds, assumed to go to just under 500 with our new tower. Our payer mix is just over 40% Medicaid. We are a safety net for children who are part of the Medicaid program. And the balance is commercial. Up until the pandemic, about 10% of our activity came from international and about 10% came nationally. So we saw children from every state and 110 countries in 2019. So we are a destination for largely rare and complex cases that truly get referred here from even other children’s hospitals.


Gary Bisbee  17:02  

Well, you’ve referred to COVID several times. How did COVID affect Boston Children’s?


Sandra Fenwick  17:08  

Well, like everyone else, it came from nowhere and we had to scramble fast. So at the end of January, we set up our command center. And it has been live ever since. So we have passed our anniversary. And we as a children’s hospital had to make a very important decision early on. Would we take every patient including adults or would we try to figure out how to be a sweet spot for where our capabilities were? And so we became what we call the pediatric destination center and a coordinating center for pediatrics both across our state, but also across the region. And we allowed the adult hospitals to care for adults and close their pediatric units. So several of the other hospitals, both here and around the rest of the states, had to do that and refer their pediatric patients to us. But then we had to do everything. We had to move all of our ambulatory clinics to virtual, so we shuttered probably 80% or more of our inpatient care on the ambulatory and ambulatory surgery side. We moved to the virtual and that became 80% of how we took care of patients up until probably May/June/July where we were able to begin to bring patients back. We had to do all the safety things – set up testing and set up our command centers where we basically ran the hospital out of PPE –  everything from masking, to goggles to everything else that we had to ensure. And we remoted virtually all of our non-essential staff. And we still have 3,000 to 4,000 of our employees, so we have about 20,000 that wear a badge, either here, on-site, or whatever. We still have 3,000 to 4000 that are still remoted.


Gary Bisbee  19:02  

The effect has been overwhelming for all of you in the frontlines of healthcare. Speaking of that, how are your physicians, patient-facing staff doing, certainly hearing a lot of reports that just this ongoing pressure is very difficult for our institutions to manage.


Sandra Fenwick  19:22  

It’s a combination, Gary, of both the acuity of when the pandemic struck and the lack of really understanding what we do. In 2015 we were designated as a biohazard site. And so we trained so many of our people for some kind of event like this, some kind of pandemic or some kind of insult. But I think no one expected the acuity and the breadth of this, nor the length of time. And I think for us that’s the challenge here. It’s not only what they all had to endure – the families, their own families, their own personal risk that they were taking home, to some extent some of the people that they lost personally, but also people who did not make it through. Less so in pediatrics, so we were very fortunate. The children during this time period were less impacted. But it still was very frightening. And I think the mental and stress that have been put on our people continues, and the burden that they carry both personally and professionally is going to be there for a long time. But the other thing that is impacting children are the behavioral and mental health issues that have emerged or have been exacerbated during this time period. And that’s the piece that’s hitting us the hardest, because we are seeing children, and we’re a destination site for a lot of them as well. This week, we had over 55 kids just waiting for a bed. After all, our beds in both our facilities were full, we’ve been trying to transfer them to other places, but there’s just not enough capacity. And this is putting an undue burden, not only on the kids and their families, but our people as well.


Gary Bisbee  21:12  

Was there an explosion in telemedicine at Boston Children’s like there was at many of the health systems, Sandy?


Sandra Fenwick  21:19  

Absolutely. We had been preparing for this. And so we had started something called Digital 1 and then Digital 2.0, where we were preparing everyone for this, knowing that that’s what was coming. But literally in a week, we went from about 170 virtual visits per week to 2,000 to 7,000 or 8,000 or 9,000 in 2 weeks. So it was just a flip of the switch. And everybody had to try and figure out not only how to deliver care, but obviously help our families and patients figure out how to receive care that way.


Gary Bisbee  21:56  

Let’s go to children’s hospitals for a moment. What are the key trends in children’s hospitals nationally, Sandy?


Sandra Fenwick  22:04  

There are only 35 of us who are freestanding and are really dedicated to pediatrics only. And we dot the country. And we are the principal providers of really not only care, but as I mentioned, also research and education. And so we carry a disproportionate burden because so much of all of those things, both from a safety net perspective, as I mentioned, but also research and education, which obviously require subsidization. And so for all of us are not only deeply committed to continuing all of those missions, but I think there’s an extra financial challenge that we have faced in the past and that we’re going to continue in the future. We have other wonderful children’s hospitals that are part of systems and they are equal partners in all of this. To some extent, they get some help from their adult partners and the bigger systems, but not always. And so they are equally challenged because sometimes they are not getting their fair share as children’s hospitals even within systems. So as children’s providers, we have lots of challenges. Again, the Medicaid program, not the Medicare program, does not fully cover cost. Sometimes the Medicare program covers more costs or close to cost. And so all of those things together, I think, place us in a difficult place. Children don’t vote, Gary, so investing in children is something that I think has to be on the agenda of our national policy, but also at the state level, and of course at our local levels.


Gary Bisbee  23:51  

Well you mentioned 40% of your revenue is Medicaid, which basically means you’re not being paid your actual costs for that 40%. I would guess, Sandy, that of the 35 free-standing hospitals, many of them have more than 40% revenue from Medicaid, is that true?


Sandra Fenwick  24:10  

That’s absolutely true, Gary. It’s over 50% for the majority and it’s now probably getting close to 55 plus. So the burden that the majority of those children’s hospitals face is even greater. And we’ve been somewhat fortunate in Massachusetts because of our commitment to trying to get coverage for more of the children population, even at the lower economic level. So that’s why we are a little bit in a different place.


Gary Bisbee  24:40  

Well, it’s definitely a mission of mercy, the work that you all do at the children’s hospitals and I think there has been a substantial trend, isn’t there, you mentioned this, but the children’s hospitals becoming part of a health system just for financial reasons, if no other reason. One imagines that will continue. Well on a happier note, let’s get back to you personally. You’ve announced your retirement, which I don’t think retirement is the right word for you, Sandy, I think just moving your energy elsewhere. But when you announce your retirement, I mean, what goes through your mind after this marvelous career of leading healthcare institutions? What goes through your mind about what will be next?


Sandra Fenwick  25:27  

Someone gave me a wonderful word. Instead of retirement, he called it refirement, or refiring instead of retiring. So I like to think that’s what I’m going to do. But this has just been an extraordinary journey for me. All through my various stages of being in research, and then being involved in a changing healthcare landscape over the last 40 plus years, to being at the best children’s hospital in the world. So, it’s bittersweet. This career has been good for me and I hope I have contributed something back. And I look forward to it. I think there are so many things that we put aside in our journey – our personal lives, our family, our friendships, taking care of ourselves. We’re 24/7 on all the time. So I think there are things that I look forward to. You know, I’m definitely committed to women and their issues, to children and the future, they are our future. I’m committed to science and technology because I think that that is where we are headed with healthcare and what will revolutionize the healthcare delivery system and hopefully make it better for all of us, especially since we’ll be on the receiving end instead of on the delivering end as we age. So I think there’s a wonderful opportunity to give back in a different way.


Gary Bisbee  26:47  

Sandy, I don’t know if it’s even possible to answer this question. But the question comes to mind, what were your greatest successes as a leader over these last 40 years or so?


Sandra Fenwick  26:59  

There have been many that have been more business-oriented – a major financial turnaround, corporate cultural turnaround, alignment of our faculty and our board and our people around truly one purpose and one mission – I think that that has been one of the greatest joys I’ve had because I feel as though we really have remembered, and we talk about it all the time, “What is our North Star? What is our purpose? What’s our identity?” And that’s something that I have tried to reinforce at every stage. I think that there have been people. The greatest thing that has inspired me is being surrounded by people ten times smarter than me – the physicians, the scientists, the nurses, the caregivers in every way – ensuring that we retain the best and that we allow them and enable them to be there, not only their best selves but also to do their best work. And so creating an environment that is innovative and respectful and inclusive, and now, not only diverse but intentionally inclusive, because I think we can be diverse and not be inclusive. This racial reckoning and all of this work has really just put a spotlight on how much we have yet to do in every one of our organizations. And that’s going to be something I want to continue as I sit on other organizations or boards. So being a voice for children, I think is something that I will always continue because, as I say, they are only 25% of our population, but they are 100% of our future.


Gary Bisbee  28:37  

Well said. Looking back on your career, let’s say you could have a quote/unquote, “do over,” is there anything you would do differently, Sandy?


Sandra Fenwick  28:46  

Always! But I think some of the hardest things, I think, we do are around people because they’re the most emotionally charged and difficult. Sometimes keeping people too long, not helping them find that this isn’t the right job or the right role or the right institution for them, making tough decisions about behaviors that are unacceptable and not calling them out and addressing them in a much more rigorous way. And so I think those are always things that we can always do better. We’ve had so many tough decisions. You know, when people around here will remember that we went through some tough decisions around patient issues, but also around a building where we had a lot of controversy about taking a very beloved garden. And it wasn’t the taking of the garden that was so problematic. It was, did we really communicate sufficiently not only rationale, but why – deeply, broadly, and with enough sensitivity. And so I think sometimes we know what the right decision is, we know we’ve got time pressures, and we plow forward, and we sometimes leave people in the dust. And so we can never do enough communication.


Gary Bisbee  30:07  

Well said, Sandy. Why don’t we land here? This has been a just marvelous interview. Your energy, as always, comes to the fore. We look forward to seeing all the things you’re going to be doing going forward. And thank you again for your commitment to children and your commitment to healthcare and your commitment to leadership. It’s just terrific.


Sandra Fenwick  30:30  

Thank you, Gary. It’s been my pleasure.


Gary Bisbee  30:33  

Fireside Chat with Gary Bisbee is a Health Management Academy podcast produced by Think Medium. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review Fireside Chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we’ve found that podcasts are known through word of mouth and we appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capitol in Washington, DC, where we explore the strategies of leading health systems through conversations with CEOs and other interesting leaders. For questions and suggestions about Fireside Chat contact me through our website firesidechatpodcast.com or gary@thinkmedium.com. Thanks for listening.