Javier: Hello and welcome to the Javier Morquecho Podcast, where thought leaders connect to share their stories. Check out javiermorquecho.com for professional development, coaching, and inspiration. I'm Javier Morquecho, your host for the day. We're joined today by David B. Vliet, BHA, MBA, and the current CEO of Tiburcio Vasquez Health Center Incorporated. It's a non-profit community health organization serving nearly 15,000 clients in Southern Alameda County in California and has an annual operating budget of approximately 35 million. Prior to joining Tiburcio Vasquez, he served as the CEO of Central Texas Community Health Centers Incorporated managing 22 delivery sites and over 500 employees. He also serves as a board member for a number of organizations. David has over 20 years of experience in practice management in health services administration. First, hi, David. Welcome. Thank you for being here.

David: Javier. Hi. Thank you so much for having me. I really appreciate it.

Javier: Thank you. And so let's start out by talking about your educational background. You started college at Shenandoah University studying theatre but then switched to George Mason University shortly after to pursue to Latin American Studies. Can you tell us about this?

David: I did. You know I like to frame my education in a way that, I think, is easy. For all to understand is I took a break and finished both my degrees as an adult. So I got my first two years taking care of...as a theatre major. Thought I wanted to be an actor. And at some point, I realized that that might not exactly be the way I should go, although I was okay at it. I decided then that at the two-year mark to leave college and go see and the world, and I did that. I went to Mexico, and I will give you more detail, I think, as we talk about that later. But I went off and spent some time in Mexico to learn Spanish and to have a, you know, a multi-cultural experience, I guess, today the equality gap, yeah, I probably should've taken one of those. But after I had a couple of years out the real world, I ultimately reapplied and went to pursue and finish my undergraduate degree and later my Master, my MBA.

Javier: And so how was the experience of going from one degree to another degree and...Because I'm thinking of someone in the audience who may be in a similar situation back then. What advice would you give to someone who wants to pinpoint their education or career path? And they could be very well in different fields of study, but how do they choose what to do?

David: Well, I think this is a really great question, Javier. I think we expect a lot in our culture. Believe it or not, maybe a little too much to expect that an 18, 19-year old is gonna have a complete vision for the rest of their life and know exactly what they're gonna do. There are few that do that. A few current fields that require that kind of decision-making early on but it seems to me that as you develop, as a young person and your brain develops and your interests develop that you become interested in different areas and potentially different fields of study. And so I think that, you know, in my case my interests totally developed as I was growing more mature and as I decided that maybe acting wasn't something that was practical for me as I went out in the real world as I mentioned. It began to shape what I wanted to do. And so by the time I went back to school, I had been in Latin America and really felt that my calling as a human being was to work with Latinos and Spanish speakers but, more importantly, I need to have an international event to ward my career ultimately would end up doing. So as I re-matriculated back in the school, I had a much clearer vision when I went back in 1988, so I would've been maybe 26 years old and I chose Latin American Studies, at that point, to begin to get an understanding of the [inaudible 00:12:25] Latin America and the politics they're in, and that course of study really did help me with that in terms of my understanding of, ultimately, the area that I work in.

Javier: So when you were in Latin America, what about being in that area gave you the interest to pursue health care?

David: I was struck by the poverty. Frankly, I was in Reynosa, Mexico in Northern Mexico on two occasions. My first time there I was really just getting my bearings to learn a language and I went through a language program, then a state program. And then I returned as an adult in 1990 and I had a much clearer vision, at that point, as to what I wanted to do. I had already begun to...my heart was beginning to tell me through the '80s about doing a project or developing a project that would bring healthcare to people that don't have access to care. So when I returned in 1990, I went through a programming and travel through a number of areas in Mexico with a family physician in the team and we did some medical outreach. It was there. It really clicked for me, and in fact, while I was in Mexico I was thinking, "Shall I go back? When I get back in United States, should I go to medical school or should I pursue more of an administrative career?" And so I went through a decision-making process while I was there. And again, I know we'll cover this as well, but I took a break from a, sort of, a partner in insurance brokerage. I was definitely ready to make a decision about what I wanted to do as a younger man and as I look at medicine, I realized, "I don't really like bones. I don't really like broken bones. I don't like blood." So I might not be the kind of person who'll be best suited to sit in an exam room day in day off. So at that point, I decided I would use my early skills in administration to develop a project that would deliver healthcare, largely, to adapt [inaudible 00:14:28] and migrate workers in Florida, that's where I was based. And I applied to Florida Atlantic University at that time. I was accepted to the Bachelor of Health Administration Program.

Javier: Oh, nice. And so, you did mention you worked in insurance. Can you talk about that experience and what you learned in insurance that may have helped you later on?

David: I sure can. You know, as I've mentioned, I took that break. And so I didn't have a degree and insurance was and is a business back in those days, and I think that it' still is, where maybe a baccalaureate degree isn't absolutely necessary in order to have a full-fledged career. Of course, we now know that...we wanna pursue those degrees I feel because we don't want people telling us, "You can't do something." Right? They also, of course, add to the entire article, you know, asset of who we are. But I became an insurance underwriter meaning that I... are basically two things. I sold insurance policies for commercial properties and then I became an in-office person where I was underwriting commercial properties, and that work was really foundational for me in terms of how I organize myself and organized...how I thought about business but it also gave me a tree. I was able, as a customer service rep, I was able to manage a book of commercial accounts and I get paid for that, obviously. And when I went back to school, I was able to do that part-time work. So it equipped me and allowed me to have a trait [SP] that I actually really enjoyed in and I needed it.

Javier: And so you said you did go back to school at Florida Atlantic University to study Health Service Administration. When you chose health services, what was it that...what's your motivation for you stick with that field?

David: Well, first of all, at that point I was really convinced I wanted to do health care and I also had this vision for a mobile clinic. And I figured, if I was gonna ask people for money to help grant fund this, I ought to have the right credentials. But if we back tracks to the early '90s, the health administration degree was relatively new. These days, the Masters in Health Administration is rather common. It's a very good degree, it's a strong degree that you can lair on top of number of undergraduate degrees that prepares you for work in the health field. That point in time, the Bachelor Health Administration was a little less uncommon but I really wanted to gain an understanding of what was out there in terms of... I didn't have any experience...hands-on experience in health care other than having a little bit of support in the group health insurance area when I was in the insurance business. But I didn't really [inaudible 00:17:39] how many secure work, work, I heard about capitation, I heard lots of terms and I didn't understand it. So when I went back to school, I was introduced to, and of course, the early 1990s is a lot different than it is today. The health care science and it was there [inaudible 00:17:56] got a really, kind of, a good background, a rigorous background and a variety of this [inaudible 00:18:01] including statistics, of course, finance, I had some social science courses that were really important. They were just...a good [inaudible 00:18:13] I went to around critical thinking, and that really prepared me both for my career. I think it also gave me an edge in the marketplace as I began to look at what I wanted to do full time in the health care program. And not to fast forward too much but I'd like to remind the young people today, internships are still a great way for people to get to know you and to develop some acumen in an area you're interested in. We have summer internship of...limited interns here at our organization. I did an internship for my [inaudible 00:18:52] project and that really exposed me to the practical workings in health care and exposed me to potential hirers, people that would hire me. So that was an important part. Even I said that point, I was a young man with a family, the internship was critical in my next steps.

Javier: So what was the internship and what did you do?

David: I did an internship with the health plan in South Florida near Miami called in those days the [inaudible 00:19:25] Corporation of America, now the [inaudible 00:19:27] later became FPA Medical Management but I, essentially, did community outreach and did a project that talked about something that was actually new back in those days which is very common now called Medicaid managed care planning. So in the early '90s, it wasn't as common for Medicaid to be managed...a local Medicaid program to be managed by a private Medicare, a private health plan. That was unusual in those days. Now we have a variety of Medicaid managed care plan. So I did a pay for that explored, that what it meant and what the potential core that market was, and that was a capitation project that I worked on.

Javier: And so after graduation, did you continue working at that organization or what did you do after graduation?

David: Yeah. I was picked up actually as a result of that project by the sister company. This was the health plan and they own and operated on a number of clinics, Medicaid clinics that were located largely in pretty low-income areas. So after I've finished that project, Jill [SP] and I met through the course of my work, gave me my first shot and hired me to manage a small Medicaid clinic in Pompano Beach, Florida and I went in with my tie on and my shirt tucked in and I had never managed a single human being in my life directly, did no match working them resources. I walked into what I call the "hood." It was a tough neighborhood. And begin my career as a medical practice manager. My first two doctors who I...one of who my very [inaudible 00:21:24] still today. I worked in the pediatrician and [inaudible 00:21:28] practice doctor and I had to learn how to run a clinic. And that's why I got my medical practice jobs, as I call them. During that initial experience, as I rose the ranks, I was given more clinics to operate to the point that I became a Regional Administrator. At one point I had some 13 individual health clinics under my purview.

Javier: So this was your first managerial experience, you say.

David: Sure was.

Javier: So how do you describe that transition of being someone who's an individual contributor to now managing people that managing an organization?

David: Scary. You know, all the school in the world doesn't teach you how to manage people and understand, you know, the rigors [SP] of managing a medical practice. I think in those days, particularly understanding human resources and understanding the dos and don'ts, I used to characterize it as...you know, a good manager learns how to stay out of trouble of HR, meaning how to directly deal with employees, coach, counsel, terminate, hire, all of those skills are really important. This is why we encourage folks that wanna become mangers, we give them...if they have a title, manager, we want them to manage human beings and have that experience so they can go through the process of progressive discipline and all of the things in managing individuals that become part of... Ultimately having a number of people, perhaps, that are one supervision.

Javier: And what do you feel you were unprepared for in that role?

David: You know, I didn't... You know, managing people, there's an art and a science to it and in a corporate setting, you've really gotta understand how to bring people along but also deal with the issue that they bring with them. I would say, I was dealing in an environment where some of the employees were prone to what's called the shenanigans. And I had no experience in how to directly deal with those shenanigans or those antiques. So I, fortunately, had a good mentor who really game me strong teaching on how to do HR. I feel like of all the school and to start off, let's just say 26, 27 year old, never managed anyone. A good background on how to do good HR, how to document, how to counsel employees, how to terminate, you know, interviewing skills, dealing with the day-to-day. I start off with four employees. Ultimately, I've had up to 600 employees. It's those early days I still look to, those fundamentals. And I tell my executives here, because of my [inaudible 00:24:37], I have much tolerance for skipping steps. You know, you really can't do a D and E if you haven't done A, B, and C. I think when it comes to HR, as it will always come back on you if you're not thorough and you don't make sure you cross Ts and dead-ice [SP]. Think in their early days, being process oriented is a very, very good discipline for the young manager.

Javier: So you mentioned a lot of good points, mentorship. And then just another idea that came across is now that you've gone through the experience of being a manager and being a leader, what do you think are the important first trainings that you can give someone in their first managerial position? You mentioned good HR and being thorough but are there other trainings or programs that you can provide someone who's just starting out as a first-time manager?

David: Well, I think HR is a good jumping point if you're managing people to start. You know, they say that most people have the skill set to do the job that they're in. Now that isn't always true. You quickly find out when someone doesn't work out. They don't have the what I call "charm" [inaudible 00:25:56]. So we talked about, you know, music in terms of your ability to play instruments. Very much the same, you very apparent [SP]. But given you have the fundamentals then a lot of it really is about fit. It's about personality, some of it. So I think that understanding the principles of HR are really important. You know, depending on your industry in the health care and health care delivery. We have a way that we do things to clean outpatient setting. Those skills are codified [SP], they are bodies of knowledge, you can get certified through the various associations like The Medical Group Management Association, MGMA. All of these organizations [inaudible 00:26:46] can certify you and verify that you've got the skill set and the knowledge to gear a job but past that, I would go back, Javier, to what I talked about in terms of how you deal with people and how you manage process and bring people through a process. And in many cases, learning should be a compassionate... Manager is really important. Compassion, understanding, and that nice mix of compassion and, often times, discipline.

Javier: And you also touched upon you had a really good mentor. Can you talk about that experience? How did you come across this person and how did the relationship develop and what were the roles and responsibilities of you as the mentee and him or her as a mentor?

David: Well, I haven't spoken to him in years and, I think, [inaudible 00:27:43] passed this link to him but my... I'll give a shout out to my first managing things [inaudible 00:27:48]. And [inaudible 00:27:50] was in the military. He was fresh out the military when I first met him. And so he was pretty tough but he had that really excellent mix where he was able to draw talent out of people. but he was rather...he was direct, he was really clear about steps and what was the next and what you could expect from him. He also had a very clear hierarchical, sort of, view of the world because he's in the military and perhaps in industries... Some industries were not quite as hierarchical as he may have been but even though he was a little heavier, heavily headed in that area, he taught me a little bit more about organizational structure and the roles that, you know, the role that you play as a manager and your responsibilities in an organization. So Pieter [SP] was a really excellent mentor to me. He was, and I feel, he was really a brilliant people manager. And I was able to watch him. You know, I like to say in music because I play Jazz and Blue [inaudible 00:29:02]. Jazz is very intermediate basis. I'm still learning it but pretty well, I think. But you can't build a cabinet unless you watch a cabinet maker and you see the new ones, the bout, the building, how you put the glass in it, how you stain, how you put the knobs on, right? I think there's a lot of analogy there as it relates to how you do your work as a manager. We ask someone to watch and to emulate that's really strong...you know, you can pick up those skills and then employ those.

Javier: And as the mentor, would you go to him for questions? How did you interact with him? Or was it mostly watching him modeling his behavior?

David: I'm really thankful that... Again, this is only maybe in 1993, 1994. I'm really grateful that he was on me like glue [SP]. I mean, he's up to me like... I mean, he also was a younger manager. He is probably only a few years older me if he was at all. I don't know. But he been in the organization longer than I had and he was really proving himself and so how I worked and turned out against he'd say was a reflection on him, so he discipled me, I think he'd say. He really invested in me and had a reason to. You know, my issues, my failures would be directly reflected on him. The organization I worked for there in Miami was very hierarchical in its nature, so that matter to him. So I was very fortunate that he had a [inaudible 00:30:47] oversight and we interacted a lot. And he really was a great mentorship. I miss that guy. I need to reach out to him.

Javier: Okay.

David: [inaudible 00:30:54]

Javier: All right. Thank you. Okay, so we'll go back to your story. You said that you started out with one clinic then you started increasing responsibility to another clinic and you eventually became regional administrator of this location, correct?

David: Yeah, for the company. So you know, it became a [inaudible 00:31:13]... To me, it became apparent. Once I got my bearings and I was on the job that this was for me. And I started with good guidance from [inaudible 00:31:23]. I began to understand and get a feel for how to do this and I think that was evidenced both that own the company and to my manager that I was able to handle more than I had, so they added additional clinics to my group and I managed... So these were, ultimately, [inaudible 00:31:50] health centers by his company. I eventually took a transfer from South Florida to Orlando, Florida where I ended up having the Central Florida and Northern Florida areas as my region. And I think, I mentioned that was 13 clinics at that time and those were spread all the way from St. Augustine to Jacksonville to Tampa [SP]. And so I did quite a bit of traveling but that also helped me understand what it meant to operate a multi-unit shop across a broad geographic area.

Javier: And so you oversaw a budget of $10 million, you're responsible for recruiting and contracting positions, billing, selecting practices, running the information systems, doing purchasing and supply training management, doing reporting and analyzing data on physician productivity, you had to look at patient flow, wait time, in patient and outpatient utilization. How is it possible for one person to accomplish all these and to oversee everything and to make sure the whole region is running smoothly?

David: You know, as you're listing all those things that I was thinking, "Man, I forgot how much fund that was." And I've got but all those things that were thrown at me. To tell you the truth, these sound more daunting than maybe they were but this was just the fundamentals of running a business. $10 million budget may sound like a lot to a lot of folks. I've had up to a $70 million budget. I've been responsible for both large and small, but those are the fundamentals of business. I had to wash the PNLs, I was responsible for the various profit centers, and I really just...you know, [inaudible 00:33:45] one bite at a time. There wasn't a lot of time, a lot of patients supported me but I feel, like, when you're ready for something and you get on the bike, you get on the horse, things come together: the balance, the energy, the creativity. And so I learned all those things pretty much on the job and I will say, I feel that my undergraduate education really helped me, particularly in the area of writing. We need to do a lot of email in the early '90s but I was able to write effectively, write proposals. I had guidance, of course, and I had some pretty serious opposition challenges from the folks that I've worked with on occasion which maybe the worst thing, but I think that as I did it, I became more intrigued with it and I will took more on.

Javier: What differences in leadership or management styles were there from managing one clinic to managing the entire region?

David: There is a specific skill set in practice management as it relates to dealing with providers, physicians, people who provide the care. In those days, there was a lot of time spent coaxing providers to see patients and to manage the care of our men [SP]. That has changed. The models have changed a little bit. Providers, doctors are often set advice to see more patients but in those days, because they were getting paid a fixed salary, often times it was a real struggle to get the volumes and the productivity up. So a lot of time was spent on, you know, coaxing and encouraging doctors to see patients. That has changed a lot since, I think, in the world, we're currently in for a number of reasons. But I will say the primary, you know, skill was really learning how to...you know, on top of the human resources part, how to scale the work and deal with larger numbers of people. But then, as you grow in your span, you have a smaller number of people to manage, people who manage people, right? Supervisors, directors, and that was a new experience for me, managing people who manage people since I don't know all that direct management prior to that myself.

Javier: So what would you say is one takeaway that you learned as you scale up the management?

David: A takeaway that I have as it relates to managing people directly is that you've got to be very... This is a nice [SP] combination of things, I think, maybe for your listener, but strategic and sensitive at the same time. It is human resources. There are times in your career, for those that are listening, when you may feel like, you know, you've gotta get a few notches on your belt, you've gotta do a few terminations, and you've gotta cut...maybe do some layoffs throughout your career, make some difficult decisions, often times, you know, you got your reduction forced in order to meet budget. I would encourage you that while you do those things that you remember the healing part of what you're doing and the compassion and understand that, you know, people's lives matter. And I think that was something that I have to learn and I did learn as I grew as a man to take way. To answer your question would be, you know, be human, be compassionate, be thoughtful and careful. There shouldn't be a lot of fighting just sort of cowboy and a cowgirl and [sound] for the sake of doing that. So tell us your pressure and the bottom line what will open drive that but do that in the context of human compassion.

Javier: Oh, that's really good. And you did say it was a lot of fun, you had a lot of energy, a lot of creativity, but you also mentioned that you had to have balance. So were you working, literally, non-stop around the clock at this point or how was the schedule pretty normal?

David: I was working hard. At that point of where...now in my career, I was traveling across Central Florida and going to different clinics and doing visits and audits and... You know, it's in our notes, we talked a little about this in our pre-interview but I had exposure to a very abusive executive in the organization, something that I think, we've definitely wanna talk a minute about some point. I didn't know which to enjoy those times because, you know, as I even reflect, could 15 years of now back on those times... Times could've been a little more fun. They were difficult. I think that's okay. You're early in your career. You know, you've gotta go through some things so that later you become an executive director or CEO, you've been through all of those experiences that make you the person that you are and make you suited for the job that you're gonna eventually be in. But I would say that I took way too much abuse from a particular medical director who just had an abusive personality. And I wish I had reacted differently but as I look at it now, there's no excuse. Under any circumstances to take that kind of abuse. I wish I had used the HR resources that I was still training then to address the way he way was treating me. But it made the job on lesson until finally I didn't work from that company but I still think of that individual every so often. Word got back me years later that he treated me like that because he thought I was talented, that was a reward for being talented. I didn't really need that if you know what I mean. I think that's an important point here. Be the manager, be the director, be the CEO you'd like to have. I learned later as I moved on to the [inaudible 00:40:02] organization that the culture...the organization is largely set, of course, by the people and it's set by the leadership. How you speak to one another, whether you tolerate certain types of language, we are very aware of now and have all kinds of training against abusive behavior, sexual harassment, that wasn't the situation here. You know, but if we want to have a culture or...like I said, be the manager, be the director, be the CEO that you'd like to have.

Javier: Yeah. And one more question about that. What advice would you give to someone who is undergoing adverse circumstances or a hostile work environment similar to what you mentioned where you had someone who really was opposed and gave a lot of struggle?

David: You know, you just remind me, Javier. I don't know that we even had any training that's... As far as I can recall, the early '90s were on a hostile work environment. That's exactly what this is. You know, and I think I wish I had that tool available to me to make that report and, maybe, make things better. I don't remember exactly the entire part of your question but I would say this. Clearly, the things that we accepted in the workforce years and years ago like how women had been treated and marginalized, underpaid and other flaw in the workforce, you know, relegated to certain tasks. We don't accept that anymore. And as soon as we see it, we identify it and we call it out. The things have changed in the past 20 years. 20 years ago, I think, we were still in a place where these were common practices, these were common trainings, and for those millennials that are listening to me and younger, they don't tolerate this at all. I mean, as far as our concerned, you know, there... I have a niece who I just had a conversation which is 25 years old, as is my daughter, and they have different expectations and don't tolerate certain behavior from employers that we once did. So to answer your question I think that be familiar, understand the policy and pull the trigger when you need to for your own good if it's necessary. Other than that, then work your management structures. Often times we know that you have to manage, and not everybody is easy to work with, and part of the challenge is sorting through, how you work through difficult management structure or individual or a high-pressure environment and it's up to you to figure that out and often times you will grow through it and you should grow through it.

Javier: And so we'll go back to your story and there's a lot more I wanna talk about which is what you brought up. But you said you went to Nemours after, and you were a Senior Manager for Clinic Operations. You oversaw operations for the pediatric medicine and surgery practices. How is this role different than the Regional administrator position in the previous company?

David: Well, those in health care will be able to that working in the for-profit...this action is really across business. I think in general, moving from for-profit to non-profit is pretty significant change. That's what happened here. The companies I worked for worked for profit company [inaudible 00:43:51] public health. So I went off to work as Du Pont Related world class pediatrics specialty clinic wherein Mr. Du Pont, Alfred I. du Pont was a Florida entrepreneur and Maverick had left the bolus of his wealth to the establishment of a clinic that would take care of children with special needs without regard for their ability to pay, and noticed then Nemours Children's Clinic. And I felt like I had died going to heaven. I went from two different environments, from a highly pressurized environment to a very mission-driven, client-focused environment, and it was a completely different world and it was, for me, a very much needed change and has served as a foundation for all of the work that I do in terms of health care as relates to compassion and having service available to those that need it. Now, the work was quite different because it wasn't primary care. Primarily, it was pediatric specialty care, and so there I learned the rigors of private practice meant should, and what it meant to manage a subspecialist and divisions within a multi-specialty practice. So I had 18, at one point I had 18 practices. Half of those were surgery, general surgery, pediatric surgery, urology, couple others that were formed [SP] in there, ear, nose, and throat. And I had the medicine divisions as well: pulmonology, gastroenterology, the nonbasic, I guess you would say, types of specialties. And that was a fantastic experience. It was there that I learned about the relationship that an outpatient practice has with the hospital. And I learned many of the things that I've used in my career were so important in that role, have been informative. A lot of it has to do with the analytics and understanding the money and understanding payer mix [SP]. In 1999, where kinda health records were not as broadly used as they are now. I had the experience of implementing Epic Health Record into an orthopedic practice. I like to joke and say we did this in the middle of the summer when kids were getting injured. It was huge disruption and I call it "The Valley of the Shadow of Death." That wasn't the time when the police [SP] introduced a mechanical [SP] health record into a medical practice. But it was really, really a difficult operating experience. That whole experience working with an organization that was dedicated to providing health care to kids that didn't have it. I recall of the many medical professionals that I worked with and admired the most, the nurses in the hematology-oncology area, the cancer unit were the most passionate, often times, difficult professional in the building. And the reason was they loved their patients. They had a real passion for those kids. They protected them, they didn't like sh [sp] at administration often times introduced, they were very patient care focused. And it was there, I developed a very patient, I think, customer-oriented focus during in my time in the children's clinic.

Javier: At this point, within one year working at Nemours, you had an opportunity to get an MBA.

David: That's right.

Javier: And you went to Nova Southeastern University and you had emphasis on entrepreneurial studies. So what did you learn at an MBA that helped you with your career at this point?

David: Well, here's a lot I learned. And that is [inaudible 00:48:09] as CEO is that it is...it was a rare opportunity, fabulous opportunity that this organization gave me and that they agreed to pay for my master's degree. Essentially, when they hired me... Again, it was Du Pont related, so they had a pretty robust tuition reimbursement program but didn't have to do what they did. And that was that they compressed five years of tuition. I think it was roughly $20,000 worth of tuition for me to pursue and finish my MBA. That's one of the greatest gifts, I think, I've ever been given, apart from all the gifts of life and all the other good things, was that my boss, my mentor, Bill Lender [SP], a pharmacist himself who went in MBA, agreed to let me go back to school part time and I did all those evening hours and started to slow [SP] away that MBA, working at night on courses on accounting and going to class over the weekend for 22 months. You know, without that support, I won't be standing here today having this conversation with you. That degree program opened doors and really, essentially, assured that doors won't be shut where they could be shut because I didn't have the credentials to do that. But it was wonderful opportunity and they did have a policy where you had to stay for a certain number of years in order to repay, and I did do that as a way of gratitude. I had no problem doing that but I'm so grateful that they embedded that into my position. So I've worked really hard. This organization makes sure that we have a tuition assistance program. We just launched it. I want employees here who...if they have an interest in academic track, can go from, you know, nurse to LBN to RN to MSN to perhaps doctor degree of nursing of even go to medical school. I had a provider in Austin where I was CEO for a number of years who start off as an NBA, Fox [SP] Howard. Many years later, he came back to us double boarded in internal medicine and pediatrics. So he is an extreme example of what happens when someone sets their mind and does all the academic training. There should be support for that. And fortunately, we've had the support of our board to embed some tuition assistance, so we can see, folks, go get that finance degree. They wanna work in finance or they wanna learn about HR, if it directly relates to their work, their study, or it's your potential... You know, in the health care field, anything gets, with their agreement that it's relevant, we will help support that.

Javier: And so given that you did entrepreneurial studies as a focus in your MBA. Did you want to start a business or what about entrepreneurship did you learn that either starting something on your own or bringing that skill set back into the company and be an entrepreneur within the company? What were you looking to get with that part of your education?

David: I was, and I've been pondering this lately as we gain some attention here in Hayward, California for our firehouse clinic which is an innovation that is new and unusual. I've been thinking about what I gained from a program that taught entrepreneurship while not starting or running my own business. But I think that it gave me the mind set that within the context of a business that you don't own, you have an opportunity to be innovative in entrepreneurial, and that is seeing and sizing up opportunities that might benefit, obviously, the organization, fulfill its mission. But that are out of the box. Innovation, one of the definitions that I like about it is that it requires alliances, typically, that don't currently exist. And one of the things that I enjoy in terms of innovation is connecting with community partners, connecting with, maybe a not so obvious, partner. Sometimes they're obvious partners. So the connecting's an important factor. And how you go about creating something innovative and new in entrepreneurial that way. And I think that's what I learned in my program.

Javier: So in general, I wanna just ask a few general leadership questions. At this point in your career, are there any books or other people who have inspired you along the way to help you to achieve more?

David: Yes. I've had a note saying [inaudible 00:53:03] this question but "The First 90 Days" by Michael Watkins is the... There's so many good ones, the Peter Graper books and all of those, but I like "The First 90 Days." And I think it's a good applicable book for any manager, any new supervisor, any new executive, any new CEO to an organization. The [inaudible 00:53:29] is that you go through, after assessing the position and you developed a plan, a 98 plan which you could extend in 280 days and you turn that into a working document with measurable outcomes and measurable goals/objectives. And having a new COO, that I recently hired, who's done just that, it's proven to me, once again, how effective that is. It simply a very clear outline of all the work that he's going to do. And then we sat down recently, went back over that, and I can see exactly what he has accomplished, and he's accomplishing great deals of these objectives that he set out. I like that about that book. I think going into a new position, one of the favor you can do yourself is present to your new supervisor or your board of directors, having done the necessary assessment, given the level of stress the organization is in. And sometimes they're having the time to do that, sometimes that is the plan, to take up [inaudible 00:54:39] out of stressful situation but if it's not, then you have an opportunity to create a longitudinal plan that's measurable, that tells your board, tells your supervisor, tells whoever you report to, what you're up to and what you're going to accomplish. Some of those are tangible, some of those are not. Cultural shifts, often times, take a lot more than 90 days to accomplish but fixing operational problems, low hanging fruit [SP] can often times take certainly less than 90 days in some cases.

Javier: And just generally, what has been the role speaking up or giving your opinion, especially if it differs with the organization or the culture? When you are in a new role, how important is it to do that or should you not give that opinion at first and give it later in a different context?

David: Well, I would you to clarify your question. If you're talking about the CVO had, it's incumbent [SP] upon you. You're hired. For the most part, to give that opinion and to speak up, and you were coming in in a different role, you have to evaluate that, you have to understand the context that you're running [SP] and what you has to offer, I guess, would be one way. So I think it varies. Certainly, if you're coming into an organization as the head person and you're charged with, you know, making change, it's your...its incumbent upon you to speak up and help design change. I did that using some tools from a previous position by establishing pillars that I thought were important for the organization. And [inaudible 00:56:24] now when I first came in, I characterized what I wanted to accomplish in the first year using three pillars: access, quality, and culture. I realized the organization needed to provide greater access to the community, to the care that we provide. I wanna make sure there was focus on quality care and I want to make sure there was a cultural shift that said to the community, "We're here to serve you." So I organized my objectives around three simple areas. This can be found in the literature that most of the people, essentially, can find. But organizing your efforts around three or four very specific goals is an effective way to get the [inaudible 00:57:09] moved on organizational change.

Javier: Okay, so we'll go back to your story, and I'll talk more generally about leadership lessons later on. But it's good that you said there's different roles as a CEO and not as a CEO to understand the context of the environment. But after receiving your MBA, you became the COO at the time what was called Central Texas Community Health Centers, and that was one of the largest community health center systems in Texas. How would you describe that experience?

David: Well, that was my first executive role. So here I was having just finished my MBA. I was at the Du Pont Related Organization. I've been there almost five years, and I felt like it was time to change. And so I applied for and received a position with the City of Austin, City of Austin, Texas and they actually, which is unusual in this particular model care though and, they actually held what we call the "Federally Qualified Health Center/FQHC. So in our operations at the department of City of Austin, these health centers across the community. They would, kinda, let be called, probably in old days, Public Health Office. But they had just recently gone under a change where it had become Community Health Clinics. So they needed someone who had been in the private practice sector, essentially which is where I was, to come in and modernize the practice, and I was hired to do that. What I found was that I was an Assistant Director in the city structure, in addition to being a Chief Operating Officer, so I end up with this fabulous opportunity to learn how municipality inform the public and to the environment works while running a health outpatient community health center system that was part of that. And so I'm very grateful for that unique experience. I got, sort of, a dual exposure by taking that position. I went in as a new executive. I had never been an executive before, so that was my first entry [SP] to the executive ranks.

Javier: And within three years, you're appointed the CEO of that organization and you had oversight for all aspects of the organization and you had to report to a board and serve the community. But in 2009, you led the transition of the organization out of the City of Austin Department to a non-profit which was called CommUnity Care. So can you talk about that whole transition?

David: Sure. I think the part we don't wanna miss here is when I became CEO from COO and that is through the succession plan that was in place that allowed the after the CEO that have been there, that I reported to for the first three years, she moved on and took me at the position and the board selected me having been the incumbent COO to become CEO. Doesn't those important time of my career? I was 39 years old at that time. I had cited that point in being a CEO. In health care, I wanted that role and I worked hard but it was my first experience being hired and fired, hiring but not fired. A board fires and fires the CEO. That was my first experience, being by hired by a board of directors. So I now had a new management skills, I wouldn't have to learn. That is how you manage a board of directors. Certainly, there are many books written in governance that your listeners can read about but that is, from a personal point of view, has the one of the most pleasurable, often challenging but most rewarding parts of the work. It's working with a board. Now, in our model of care, more than half of the Board Members must be patients of the health care operation that you're responsible for. That's what the Federally Qualified Health Center Model is. It's a long-standing model. Has this truth inside that [inaudible 01:01:27], I won't go into great detail but the majority of the board must be consumers of the services. Naturally, that's really a different experience because those Board Members are actually patients of the system, and they'll tell you what's going on.

Javier: Yeah.

David: Many times, Miss Julia [SP] would tell me exactly what was going on when she went it to get her care and it was very informative. It helped me understand what the patient's experience was, what the follow-up through his life would be environment of care was, and it's a really proven methodology. That is why the least have crossed our movement also known as the Community Health Center Movement. So that was a really extraordinary wake-up call for me, was having to, now, manage a board of people that I had never...I never done that before.

Javier: Yeah and you're right. I did skip. We should talk about, like, the transition from COO to CEO. What do you think were the skill sets that led you to stand out to be the one chosen as CEO? Because I'm sure there might've been other people also wanting to be the CEO.

David: Well, I think in our case, there was a specific [inaudible 01:02:40]. There was a specific transitional plan, succession plan that... It became clear when I got there that I would probably be removed into that position when my boss at that time the CEO, who [inaudible 01:02:59]. So I had the support of the board already and there are times when, of course, you are going to compete for the role, and they're gonna put out an IRP or International Recruitment Proposition and, you know, maybe been in the organization for a long time to find that you're not competing for the position that you want. I didn't experience that in this case. I was selected. They had the [inaudible 01:03:19] on me. They nurtured, they brought me along. And I felt like that, sort of, the byline [SP] of my career arch in my trajectory that had great support. All along the way, I don't feel like I've had or I've hit a wall. I feel like there's been great support, I think, particularly the African-American in the '90s. I personally felt like there were opportunities that I couldn't should cease both for educational funding and for, you know, in terms of opportunities. And I felt great support for that. So as I moved into that role, the thing I would highlight is it's a different pair of shoes, it's a different share. Being an operator is different than being a CEO. There's a different leadership quality that's involved. Same story about that you hear frequently about whether CFOs make it or often able to make a transition with this new role. Much different dynamic, it's definitely different hat [SP]. And I was surprised, frankly, and shocked at how different it was. How you go from doing ranch work to more architectural and more planning, more strategic work, and a lot more...in the field, I was in an area, I was in much more, sort of, connecting in public relations where community-based relations and politics. Those become much more apparent, I think, for a lot of folk that have never been in the chair before and they've come from a different position within this easily.

Javier: So what did surprise you the most and what...well, I have a bunch of question: What surprised the most? What about their supports and their nurturing helped you to ease into that transition? So maybe we'll talk about those two first.

David: I think the politics were among the most surprizing to me. And in an environment I was in the work politics that had me dealt with, the organization, I was responsible for received...property tax dollars and where there are...where there's public funding, there's high levels of accountability. In Austin, the department that I ran often was covered by the news media. So there were things they consider theirs in terms of making plans that were transparent and that the public could support. There was what I call "sequencing" that you had to learn. In public service, you really can't do C and D if you haven't done A and B. You know, you really have to be sequential when you're dealing in public, in public sector because you will be held accountable when steps are missed and this... Again, I talked about, Javier, the rigors of the HR process I learned early on. Working in a municipal environment taught me a lot about business processes and the sequentially related to that as relates to doing RPs, to making sure that notifications happen a certain way, that the right people are reformed. Yes, I reported to inform but also, at the city manager, do most accountable. So managing those various dynamics and the processes therein was very, very good experience for me. And so I spent seven years in that environment being, I mentioned before, as an Assistant Director of the municipal structure. When I became CEO of the health center, I also became the rank of City Director, the city structure. We should meant them I appears with the fire chief, the police chief, the head of housing, public works, the utility. So I was on a different level dealing with some pretty high level peers, as in pretty high-level executives and I learned a lot from those folks. Talked about understanding how to navigate difficult and, often times, very treacherous and full of obstacle, at time, obstacles pathways, I learned a lot watching how these folks managed through that and was very, very useful.

Javier: So yeah, I wanna talk about... You did... Eventually, you transitioned the organization out but I would... Do you have a story of one of those difficult or treacherous scenarios that you did overcome and you did go through and what you learned from that?

David: I've had so many worst cases. It's unbelievable. The purpose is, Javier, I think, since you pointed out the fact that I had to transition te department from a city department into a non profit. This happened by operation of law. The voters of Austin created a health care district and so the health care funding was now not being collected by the city government, it was going to be collected by a taxing entity, and that forced us to move all the health care services out of the city structure. Now, let me just tell you. People who work for cities and counties have a certain culture. There is a... There's a way about that environment. There's a security there. There are some really good benefits that larger entities have. Now these folks that I had, at that point, I'm gonna say we had many, 300 or 400 employees. They were not interested in moving out of the city and losing their pension. I also had a very nice retirement plan with the city. We had to figure out how we were going to create some reciprocity of not giving exact term to make sure that their service transferred and that they didn't lose anything, there was a lot of pushback in making that transfer. It was very, very tricky. The employees in the beginning certainly wanna do that, they didn't wanna leave the city, they don't wanna leave the protection of the city. But we knew that it was the right thing. We knew that we needed admission to the fact were compelled to do it. To step our game up and become more community-focused and community-based, required no longer being attached to the city, no longer being viewed as a department of the city but instead, being a non-profit with significant funding from the taxing authority, we hope would give us the ability to do more creative, innovative entrepreneurial things in the community to raise the health outcomes of the community through effective outpatient care. And I think that's exactly what happened.

Javier: And so what... I'm just curious like, as you're going through this transition, what kind of conversations are you having with the board in order to come up with this plan? Or who are you mobilizing for help? How do you go about reorganizing it when, yeah, there is a lot of opposition? And how do you come up with that higher mission or how did you come up with your strategy to move on?

David: I would say it was a heavily project met. You know, a lot of project management... So let's just talk the operational level, certainly, they were all the moving parts that required, you know, moving IT out of the city structure. But in terms of higher strategic objectives, Javier, there were committees and folks from each organization: the taxing entity, the city itself, and then the future organizations that sat down. We planned this as a detail of facts [SP] as we could. We had a target date where the federal government would move our FQHC which stands for Federally Qualified Health Center status from the city to this new organization. So we hard date when we would, "Chada," become that new entity. So we had the project manager, we had to be very clear around strategy. As I mentioned, anytime we're dealing tax, dollars you gotta be clear, transparent, articulate, communicative, and engaging. And, on many occasions, we didn't do the job we'd like to have done. I think that we did a pretty good job in keeping the public informed and the employees informed. So it took real thought and real hard work to make sure they understood what the strategic purpose are was... We all spent a lot of time explaining to the people why we needed to do this. I'd have a narrative to do that.

Javier: Yeah, and do you... At this point or in any point of your career, do you ever look outside of the organization for inspiration or other examples of something being done that you then bring in that thinking or knowledge back into the organization?

David: Well, I hope so. I mean, we are the, particularly as the heads of our organization, we're supposed to be the thought leaders. So I'm always collecting and observing and listening, going to conference... And you and I met at a conference where a great number of ideas among some very successful peers. They were session sharing best practices. So yeah, absolutely. Collecting and getting inspiration from others is absolutely important. You should ingest that and then meditate on that and figure out what is applicable and then figure out how you're gonna roll out those things that could've impact your organization.

Javier: Now, going back to the reorganization, how do you people accountable to accomplishing that new change when they were opposed to it originally?

David: In that case, you know, your question...that was the question in your list here and I thought it was related to, and probably is, to how we keep... how accountability happens.

Javier: Okay. Yeah.

David: And I can answer that statistically [SP]. That's a really good question. And I think people are interested in how do you keep each other accountable.

Javier: Yeah, okay.

David: Well, related to that project, there were very clear accountabilities. And in fact, one of the accountabilities I had, was to ensure that the organization was as productive as possible. That was something we knew and that the city, rather the new taxing entity to have its own board required of me. And that was the challenge I had in my career there, was moving that organization to more of, I guess to say, ideal state where they were utilizing tax dollars to the number of care as effectively as possible, and that was a daunting task. It was a daunting task to take systems that are often times conditioned you, they've always done and then ask you to do more. So the accountabilities have to happen and those are, in my view, those are done through very clear plans with objectives that are measured. As it relates to the work I do as a CEO now, and I know my colleagues CEOs that are listening will agree with me. You know, if you're running an organization in a team-based fashion with highly confident people around you. I've got a group of vice presidents and executive vice presidents, CEOs, CFO, CAO, I've titled so many executive vice presidents. These are folks who keep me on my toes. My work was to hire people who had really good chops in their area. And I worked hard to do that. I probably even spent a little more than maybe I had to on finding talent that I didn't have to babysit. These are people who bring ideas to me. They are ahead of the curve. I think that that's a part of what a coach does, right, on a successful team when there's majorly feedbacks or hockey team, wherever may it be. You're looking for talent that knows how to bring it and knows how to react and is looking for their next challenge. Time ethic [SP] accountability, I feel like that comes through performance reviews, sitting down and having discussion with the people that you work with, and most people, wanna do a great job, most people wanna be effective, particularly at the executive level. They wanna do their work but what...you can give them an exchange, in my opinion, its high levels of our time. Meaning that, and you've heard me say this. That I feel that when you give your domain away instead of hoarding it, and if you're a person who isn't threatened by people being successful in organization, then you're gonna be a successful leader. It's my expectation, by giving my domain away, that people will take that and cultivate it. I want them to learn as much as possible because ultimately, I want them ready for [inaudible 01:17:02]. To me, that's a huge reward. So give in your domain away. Let the people experience that it's critically important. I think, there's accountability in that.

Javier: Yeah. So as you say interest is to share your...an executive interest is to share your domain and to get people to a place where they need to go. So what does this mean in terms of, like, mentorship or nurturing or yeah, giving them their responsibility?

David: Future leaders, simply put, we can afford, particularly in this particular model of care, we have a strong position going back to the 1990s. We have some four bearers. Odd to say that Tiburcio Vasquez Health Center started with its hands on the dirt. Someone, way back in the '60s and '70s said, "We need health care in Union City, California. And here's how we're gonna do it." And they made it happen. And that happened across the United States that many visionary people who came from the Civil Rights Movement worked very hard to make sure that this particular model of care grew and was available to the communities across our great country. They're retiring and they're gonna retire. I'm 54 years old. I'll retire in 11 years. It seems like a long time but it'll go by fast. I really have the best of interest in making sure that there are people who will carry the torch that are behind me that will make sure this work goes on. And I want them to equipped, I want them ready to sit in this chair and to have the vision, the passion that our forefathers in this work, back in the '60s and the '70s, the great leaders that you can hear by going to NAC... nachc.com. You can read an overview of our work at the national association level. These were hardworking people who stood up this health care system that now employs, 150,000 plus individuals, we see some 28 million patients a year, we are spread throughout the country in 9,000 sites, they're about 1,500, 1,600 community health centers in the United States Federally Qualified. So our backbone is the passion and the leadership that makes this model work. And if you've been listening to the news, we are a bipartisan movement. People like health centers, Javier because the return on investment is very high. Keep people out of the ER, we reduce the long-term cost, the longitudinal cost. When you don't go to the ER for toothache or for earache and they're being seeing quickly here. That's a savings of the entire health care system so that's the goal, is to make sure they are future leaders who understand how the economics and the passion work.

Javier: So I do wanna talk about that, but just going back, bringing the story back to where you are now, or where you were a few years ago which is the CEO of CommUnity Care. You scaled the business from 35 million to 68 million. In your time, what were the challenges of scaling the operation? Was it the fact that it became a non-profit to allowed to gain additional funding that, maybe, something in the city environment was holding back or what factors could it been?

David: I wish I could take credit for, you know, some incredible genius that I have, which I don't, that allowed me to, sort of, figure out how it is nearly doubled the budget. Here is what happened. I think that shepherding it and guiding the group with the help of many others, was a large part of what I did but more funding became available, more opportunity, the opportunity to open new sites and new health centers. We opened up several new health centers including the $25 million facilities in North Austin that added some, I'm gonna say, $10 million to the operating budget. So as we grew through opportunity, the budget grew. A little different than in the commercial scaling that you might have in a for-profit. Nonetheless, these were dollars that now were available that need to be leveraged and were destined and designed for health care. So the real work was designing how those services could be scaled, expanded, and those ours to be used effectively to bring an ROI, return on investment, that ultimately would bring a lower health care cost in the community which is something we're all interested in. When we see higher cost, of course, then we see higher health line [SP] cost and those will show up in our when we get our pay check every month, we're paying higher premiums.

Javier: Is there any other lesson or idea you would wanna share about that experience at the CommUnityCare?

David: Well, I think that often times, those experiences come to you, you need to be ready to push out, right? And to develop and expand, and then sometimes you also need to be able to react to problem and grow and guide so that's a two, twos often times, different scenarios where you're going out looking for money and spending four there is funding available and you're figuring out how you're gonna leverage and how are you going to, you know, turn 50 cents into a dollar and that's the exciting part. If you ask me about the entrepreneurial aspect, there were times when we, you know, we would think about the dollars that we have and how we're gonna leverage, who we'll partner with, how do we make that 50 cents into a dollar. That's a lot of fun. That was the entrepreneurial part that, I think, I extracted from those experience we didn't learn necessarily in school.

Javier: And also, one other thing. While you were at that organization, you were elected to the national board, and which I believe was National Association of Community Health Centers.

David: Yes.

Javier: So you were the youngest person there. And looking out there wasn't much diversity on the panel. So how did this make you feel and, I know you did touch up on sharing your domain and providing opportunities for others but, yeah, just maybe give more perspective of what you felt at that time seeing that.

David: Well, I am have actually recent...since I moved to Texas to California, I am honored to have been sent back to the national board by my peers here in California. I gave that seat up and came here, and I'm going back. And I do think that it's an honor to work at the national level policy for the health centers across United States in the National Association. What I feel, of course, is important is that we remain as diverse as possible. We have a relatively diverse organization and I think my colleagues in the organization would tell you that they definitely wanna see, you know, a cajur [SP] of young, diverse health center leader come forth. And I would like to help do that. And I would like to make sure that there is a pathway to national service and participation where, you know, a variety of skills and skill sets represented, with that we have good diversity. And so I'm glad to be invited back on the board as I...as you did mention, I do believe I was the youngest person on the board that time and about four years ago, I was 45 years old, something or almost. In my late 40s and I felt that there needed to be more youth involved, younger board members and I hope to see that happen.

Javier: And before going to your current role which is the CEO of Tiburcio Vasquez, I'd just have a few more general questions.

David: Sure.

Javier: At this point, you're already the CEO of a 70 million organization, you're on national boards, what do you think were the factor that led you to be the CEO or you to be the youngest person? What was it that you felt you did throughout your career that led you to that point? At so young, in your 40s.

David: Well, at that point, I had been working in Community Health for 10 years, and that's actually not that long compared to some of my colleagues who, often times, have done this for 30, 40 years. I'm getting ready to start my 60th year. I'm still, in some ways, junior. To answer your question, I think, passion sound so cliche. But if you're really [inaudible 01:26:14] in this work, interest in improving people's health outcomes and you work to that end and you place that first and foremost along with the sustainability of the operation that the organization you've taken, I think that speaks a lot. And I hope that's what happened, that my passion, my interest in this work, in being a torch bearer, hopefully, was evident. And I think that that it has.

Javier: So you did talk about, yeah, mission driven purpose and having a passion, so what...when did you realize this was your purpose? I know you talked about your college or as you did your trip to Mexico and going through your career, you realized this is what you wanna do but how did you find what your passion was, and how did you find your purpose was throughout the career?

David: Well, Javier, I think, in many ways, we're the sum total of our experiences, right? I'd say, I've grown into this. From the point, I made that first trip to Mexico. I left Shenandoah College with a trunk and a [inaudible 01:27:22] and my Bible and a book or two and my birth certificate. I went it down to Mexico to go figure out how to speak Spanish and live in Mexico for a while. Having left college, I think it started there. I'm very sure it did. And that's why I said earlier, we expects, sometimes you haven't been at all figured it out early on. Took me a while. I'm just very grateful that as I figured it out, the trajectory of my career lifted me in the direction that it wanted to go and have gone over these years. So the passion, I think, develops, you know, what do you think about when you're tossing and turning at night that inspires you in your career. That's probably the things that's driving you. And I think a lot of people thought it was not money, it's about change. Often times, it's about accomplishing that speaks to other people. We know that you know, working just for the dime adds a bit of an empty feel to it. The money comes. I would say [inaudible 01:28:31] will not listen to me and I know my `colleague CEOs would agree, the money comes and, you know, whether or not proper, we don't make huge sums of money and have elaborate gold pair of shoes or plants [SP] but I, certainly, can provide for my family and my kids and my retirement and still love what I do and feel very satisfied in travel and enjoy. So I think, let your passion, let your...I know that's very cliche, but people know that it's true, that passion are lots of things, channel that.

Javier: And so what would you say your why or your cause is?

David: My cause is to improve the health of the community. And when I got back from Mexico in 1991 or 1992, I got a very bad infection, stuff [SP] infection that rendered me pretty ill and I don't have any access to care. I certainly have any money. I was going back to school at that time and I don't have any access to care. My wife, at that time, happened to be a nurse, and she gave me scores of antibiotics for me and I probably got treated but that made a deep impression on me. I didn't know where to turn. I didn't know where to get health care, and that has some part of why I feel that making sure people have access to care when they need it is really important.

Javier: Now, in 2012, you decided to move back to California to become the CEO of Tiburcio Vasquez. It's a healthcare system that serves nearly 15,000 clients in Alameda County in California, has an annual operating budget of 35 million. When you first arrived, what did you learn about the culture of the organization and how did you decide or find out what you wanted to work on?

David: Well, as a point of clarity, this was my first time to move in California, have a eye in California. My whole life as a kid from New Jersey, I thought California was the land of, you know, sun shining, the streets are paved of gold and college is free and I want to come here. So I was happy to have the opportunity to take a position here in 2012 and leave the 103 degree summers of Texas. To get out of here and to the Bay Area. And I was hired by the [inaudible 01:31:02] here to take over this health center. We are close to 25,000 patients in our panel. I got here, it's around 10,000, around through medical expansion because of the ACA, the horrible [SP] care act. When I found EA [SP], an organization that while having a very strong civil rights, sort of, root structure, have lost its way as it relates to its basic business responsibilities. It was not sustainable. WE had barely sustainable. I was doing okay, I think about a half an hour, [inaudible 01:31:39] afternoon [inaudible 01:31:40]. When I got here, it just needed fundamental sustainability work which we did. And we went about hiring more practioners and reorganizing your finances and doing just the wrench work to make this a much more solid organization than it was. It had a very strong mission. This organization provides wet services because they [inaudible 01:32:07] the health centers in some cases, and we have a very strong family support services arm. So when I got here, we were driving enough revenue through the medical/dental practice, and that was the first thing we have focused on.

Javier: And you know, I also realized, I got ahead of myself. When you're the CEO of a position of a company or just any position, what are the factors that help you to realize that, "Oh it's time to move on to something else." Like, you could've probably stayed in Texas but, and I know you said you wanted to move to California, but at what point is it time to move on to something else?

David: Well, for the purpose of this podcast, I'll be blunt. I felt that I had been there, at 10 years, I've been there long enough, and that was time for change. And the political winds were changing there in the area and some new things were coming about that were of advantage [inaudible 01:33:12] and I think, well, it was for two minutes for me to stop change that, to come up to make the change and I'm glad I did and my successor did a very nice job. They're in Austin and, I think, they're bigger team to grow. Well I felt that was time to move on and I felt that I want to take on some new challenges and start, you know, kind of, back to the stuff, I love to do which is to rebuild systems and fix systems and then grow in a new opportunity.

Javier: And in terms of succession planning, how soon from the point of knowing when you want to leave to actually leaving the organization? Is that like a one-year period or how short or long of a timeframe is it and what do you do to prepare the next person?

David: Well, I did do a succession plan well in advance of my departure, probably a couple years. That's a responsibility that usually is built into the job description most CEOs, I think in the non-profit sector. So I had that laid out, who would take over in event that I left. So I think I gave a 90-day notice once my opportunity came about and then preceded to, you know, move on and wrap things up.

Javier: Okay. And so you've been at Tiburcio Vasquez for four years now, what do you feel is your biggest accomplishment to date?

David: I'm really proud of this organization. We just went through, two weeks ago, a very rigorous Federal Exam called the Operational Site Review, and then all of us that do this work that we seen it recall Section 330, funding are required to go through. And that is we have 19 key areas, the most important of which is the quality care that we give, that we're measured against. And it's a rigorous process, so I could tell you...they mentioned about the financial gains that we've made, the expansions, I mentioned a little bit about our innovations as relates to a Farmhouse clinic which should be featured on PBS here very shortly on the news out the next few weeks from my understanding. All of that is finding Dandy [SP] but if we're not delivering quality care, then our work is in vain and accessible care, one of the [inaudible 01:35:35] and of the programs we're going to place here at Tiburcio Vasquez Health Centers was the 72-hour access to care promise. I was really sick and tired of giving the community this message. Your listeners, probably, can't see this, but that is, "Come but don't come." We either come in, you can get and see us or you can't. But let's not the give the community make signals. And so I went about making sure that we were meeting that obligation to make sure patients could be seen when they need to be seen. The patients are seen and it's highly fashioned. Health outcomes greatly improved in the E.R. utilization is reduced. So we...I'm very proud of the fact that we have equipment available, we have a health center where urgent care of business of rather [SP] same day care business can happen virtually whenever they need it but I want to make sure that we opened up we're available for the community as we're supposed to be. And we've accomplished that. My new Vice President of Operations has been very effective in ensuring that and we had tremendous support from a wonderful group of providers, and medical leadership that have taken this on and say, "We wanna be available to the community." So I wanna make sure I don't exclude that people do the work, day in day out are the ones who've made this happen and it's the people that put patients in rooms, that check patients in, and importantly, the people who set the stoves [SP] that makes, you know, who work very hard, in many cases, could be earning a lot more money over a [inaudible 01:37:17] or when they had a large houses of the choose [inaudible 01:37:19] like hours.

Javier: So what do you feel the biggest challenges at your... What's the biggest challenge at your organization that you face today?

David: Well, it the [inaudible 01:37:31] legislation is gonna be a challenge. People have asked me, the AHCA, The American Health Care Act, does have in it, to give a bipartisan, you know, movement model of care. But the fact is this, that many of us have enjoyed making expansions, added in our case, 5,000 patients to our rolls. So as soon as patients that could been seen, not all of them have been seen. But now, had qualified for mitigated result as a result of the Affordable Care Act. If the American Health Care Act is fully passed and is fully implemented, there's no chance, of course, that Medicaid will move to block reading and that the states will be left with the ability to be more creative with their Medicaid dollars but the net effect, many was believe is that less people have access to care. Medicaid member was primarily focused on pregnant women and children. ACA raised below 130 of the poverty level allowing many adults to be covered. So they had access to what they did not before. So if that goes away, it really means that there are people who do not have access to care, who currently have it now. So that's the challenge for us, those were revenues that we, you know, for the all the chance and purposes in many ways where a Medicaid contractor, our health centers sees a large of number of Medicaid. And we also see a lot of folks because our mission requires us to see patients without regard to their ability to pay. We do see families that don't have or they don't have documents. And people say, "Well, why do you that?" Well different to being a compassionate thing to do, the economics are very simple, if we don't treat people who are out in the community, who maybe don't have their documentation, they often end up in NHNDDR and are treated a much more expensive rate than they are in a facility like ours. So we really work hard to make sure we've made access to care available. So everyone in the community needs it.

Javier: what are your future plans for the organization or for the future plants for yourself in your career?

David: Well, I'm so delighted to continue to be this organization's leader and the opportunities to do more, continue to abound even within with the specter of this legislation. We still have some programmatic opportunities in terms of diabetes programs, nutrition programs, teaching opportunities through teaching community about their health. So I'm very optimistic. Whatever happens with the legislation, we're gonna continue to be here. We were here before the ACA, we've been here for 45 years across the country, so we're gonna continue to figure out how we build connections, how we leverage and how we improve the health outcomes of the community. We do a lot of dental care. We opened our health center right through in San Leandro. There had been that capacity for dental care in that area for years. My Dental Director tells me of the large amounts of bat pathology that came in that was untreated. That's symbolic to what happens in the community. They don't have access to care. The pathology, the conditions that is the current disease only get worse. So when we proactively treat those, we reduce cost for the community at large.

Javier: So now, we have about 10 more minutes for the review. I wanna ask you just a series of questions and you can answer it in a brief, maybe 30 seconds or a minute but... so for example, one of them is how do you continue learning and improving your skill sets given that there's many struggles to be a CEO and you're always encountering new situations that are unexpected or based on law or just something happens that you weren't prepared for.

David: All of the above.

Javier: Okay.

David: The situations come at you, you keep your eyes and ears open but you remain a learner and a listener and I think that's important. You can be informed by your government that helps you. Clearly, he was going a press reaction, certainly, hopefully, miraculous going on that may change.

Javier: So how do you personally stay a learner in your role or in your organization or at...throughout your whole career, how have you been a learner?

David: You know, I like to learn from other people. You really don't bring the ideas to the table by yourself as the CEO. That's ridiculous. To think that you can do it on yourself. I've got a team of five and we're adding on new chief medical officer. They bring lots of ideas. As you have called middle managements, this team that we have. Lots of great ideas throughout the organization often just won't really...well call me [inaudible 01:43:04] there would be cultivated.

Javier: So how important is it to network or what's your take on networking?

David: You don't really have to network. I was in a cab with a gentleman in D.C. whose future fiancee just opened a dental practice and she was struggling with clients, and he said, "Give me what you hear. Do you have any suggestions?" I said, "You know what, I would. I would suggest you go to the chamber events. And the chamber commerce house and the board of general commerce here. I learned something with the chambers Good chambers really knows what's going on. They know who the business folks are in town. And you can do a lot of solid networking at a chamber event, passing out a no sounds hockey, or passing out cards, participating, knowing who owns the print shop, who owns the UPS franchise, who owns the local bakery. I mean those are very valuable relationships. And then, of course, you know, if you're a member of an international association in States, get involved. There's really no greater place. I absolutely have learned so much from being evolved in my status organization have been covering my primary care authorization. CPCIM on the board and then executive committee or the past four years I've learned. Wow, what a great resource all of these colleagues are. Then working is the fun part. Get to know your mayor. They sound intimidating but you can do it. If you're in a small town, it's probably a lot easier if you're in larger town. Get to know your city council member. Make municipal connections. The talent that you live in and the people that influence policy in your town, often times, are very smart influential people. You might even wanna become the choreograph [SP] person, you might wanna become being mentored by a city council member or by an assistant at city manager. Some of these folks have tremendous backgrounds and ae very skilled in business. It's not... Two of the thing people who run cities they are public entities are but they can be very influential. I would suggest talking to, you know, your local chamber president and finding out where the [inaudible 01:45:26] might be. They might have really great ideas.

Javier: For people who are also, maybe earlier in their career and maybe also even the same of career as you but...whether you're networking or whether you're in the organization, how important is it to present yourself in a particular way? And are you actively learning how to have an executive presence or are you constantly practicing your public presentation skills or...?

David: Always. I mean, I...sometimes you get yourself into things in your life, "Why did I sign up for that? Why did I agree to do that presentation?" You know, challenge yourself. It's all free, I like to call it "medicated and salt-free education." When you volunteer or agree to chair a committee or agree to participate in a, you know, a focus group or something [inaudible 01:46:38] term, but move into an areas uncomfortable for you. Think about it as free education. And there's some key things you can learn by simply volunteering. I also suggest that being on a board for a non-profit is a very key experience. Learning how to manage a non-profit is certainly a skill in itself. But when you're on the board you can learn a great deal about their acting [SP] with CEO, and you know the finances of the organization suggest that for people.

Javier: So my question is, another question is, from your experience, like what makes a good CEO and are there skill sets that would make a good CEO that someone who's just starting out in their career could learn so that they could develop into a good CEO?

David: Well, as you're asking that question, what if you set about being a CEO in the same way that someone sets out to be a physician or a dentist, or an architect. CEO has a funny title, I don't know if [inaudible 01:47:49] did that or Fortune 500. You know, if you waste [SP] the title Executive Director, whatever works for you but if you think you wanna lead at that level, then pursue it just as if you would pursue being accomplished in any other career field. But it doesn't...it can happen by an accident but at some point, I made a decision and I wanted to do this. So then just follow into it. I had a trajectory and a strategy, and I think that's important to think about it in the context.

Javier: How do you describe yourself as a leader and how do you define leadership?

David: Those are really great questions. I would like think...I just hear a little talk about servant leadership. I feel like after all these years, you know, I feel like I've been in a few gun fights and a few notches on my belt but I would prefer now to serve the team members that I have, that are doing the hard work, my executive team. And so I feel like, I would characterize leadership as best described as being a servant to others and being compassionate and supporting those who are coming along but also those who are really doing hard work.

Javier: And so what do you think is the best investment you've made in yourself to further your career.

David: I definitely think education at all. You know, I meet lots of people who have finished their degree studies and they're frustrated about it. And I think if you want to be in a role like this, you probably can do it without the necessary degrees but I don't feel like I have wanted anybody to be able to tell me, "No." Because I didn't have something that I [inaudible 01:49:45] so education. And then I think putting yourself into situations where you're maybe you're uncomfortable has a net benefit. You come out of it having learned something and those are skills you can use later on.

Javier: What advice would you give to yourself 10 years ago or when you're just starting out?

David: I would not have taken that abuse that I took early on. Sorry, some of you are next from that, right? I would've approached that differently. But there's not much else I would've changed because I'm very grateful for the opportunities that I have been given along the way here. To me, they were very strategic and they were a blessing and I'm happy with them. I would've done this...I would have things pretty much the same way. My personal life, whole different story. Professionally, [inaudible 01:50:42]

Javier: Okay. So on your professional journey, you can't always do it alone, so are there any people, companies, or professional groups that you felt were instrumental to your success and that you'd like to thank?

David: I would love to thank... There are so many people all the way back from my friends at the [inaudible 01:51:03] firms, the gentlemen I mentioned earlier, to the people at Du Pont, so many, it'd be unfair to name them all but you know, I had great support from an ex-wife back in the early days, great support from my children so...and really great support from my current Board of Directors and at all of my Board of Directors, they've been wonderful people that have been very, very supportive. So tremendous support all, all along the way.

Javier: The mission of Javier Morquecho podcast at the share stories of other thought leaders, so are there any people in the industry or any industry that you would like to learn from or who you'd like to see as a guest on the show?

David: Oh I have... That's a really great question. There are some people...there's a gentleman who's retiring at San Franciso named John Grismith [SP] and John is fantastic individual who's done so much in the space. He's a real inspiration. I think a lot of, you know, I think a lot of...some of the traditional CEOs but a Tom Van Coverden who is the CEO of the National Association Community Health Centers is a fantastic influence as this Carmela Castellano Garcia who is the CEO for the State Association but locally, I have a set of colleagues, Mardy Linge [SP], Jane Garcia, Sherry Hirota, Ralph Silver [SP], Marty Lacasu [SP], Zedy Page [SP]. These are all colleagues who are unbelievably committed, so [inaudible 01:52:51]. Those are very dedicated in community health and I've learned a lot from them. And if you're out, thanks for getting me.

Javier: Okay. Yeah, I'll see if I can reach to them or if you wanna share your show...this episode with them, they'll hear the...

David: I plan too.

Javier: Okay. So if anyone wants to reach to you, how can they do that?

David: Please do at D-V-L-I-E-T, dvliet@tvhc.org. dvliet@tvhc.org.

Javier: And so once again, this David B Vliet. He's a BHA, MBA and he's the current CEO of Tiburcio Vasquez Health Center Incorporated. In today's episode, you had the chance to learn about his experience in practice management and health service administration. And I hope you're inspired by hearing his story and have questions that you can either reach out to him to continue the conversation. If you enjoyed this conversation, you can subscribe to the Javier Morquecho Podcast in iTunes and Google Play or join our email list to stay connected. Please like and share this episode to spread the word. And finally, we're here to continue the conversation and we wanna continue discussing topics that are important to you, so all questions and comments are welcome. Please leave us a review and join the conversation. So thank you, David, for being here.

David: Thank you. You're a sharp young man. And thank you for making this project of yours. It's very impressive and it's gonna go far. You're doing great work, Javier.

Javier: All right. Thank you. And yeah, thank you to everyone who's listening for being a part of the Javier Morquecho Podcast. See you all next time.

David: All right. Take care.