Dr. Bill Rupp

July 1, 2006 Daniel Vance

ISJ-Mayo Health System chief executive officer and oncologist leading Herculean effort to transform Mankato into major regional medical center.

Up North, amid emerald-green Norwegian pine forests that overlook crystalline walleye lakes and throngs of moose and bear and wolves, grew Dr. Bill Rupp, president and chief executive officer of 2,100-employee, $200 million ISJ-Mayo Health System.

He spent his first 18 years of life in 5,290-population Chisholm, a boom-and-bust mining outpost that straddled U.S. 169 seven miles north of Hibbing. There, Rupp’s father Clarence and uncle Glenn co-owned two businesses, Rupp Furniture and Rupp Funeral Home.

Today, 60-year-old Dr. Bill Rupp is a nationally recognized expert on delivering healthcare quality, a practicing Mayo Health System oncologist, and the overseer of Mayo Health System hospital and clinic operations in Mankato, North Mankato, Waseca, Lake Crystal, Madelia, St. Peter, Le Sueur, St. James and Springfield. And without a doubt, he owes much of his success to his Chisholm upbringing, and specifically, to his father Clarence.

“He died in 2004 at 81,” said uncle Glenn Rupp of his older brother Clarence in a telephone interview with Connect Business Magazine. “Clarence was sincere, intelligent, so very gracious, a hard worker, a pleasant smile—he really cared and had empathy for people.”

Inside their family business, Glenn ran Rupp Furniture, and Clarence, Rupp Funeral Home. As a result, Bill while growing up was exposed nearly every day to death and dying, grieving families, dealing with the public, and the many economic challenges facing a small business—fertile training ground for a future cancer surgeon and hospital administrator.

And to think young Bill Rupp almost went on to study mortuary science and take over the family funeral home business. Believe it, a great number of people employed by Mayo Health System—and his oncology patients—are thankful he didn’t.

How old were you when deciding on being a physician?

(Laughter.) I was in the military. After graduating from Dartmouth College in the late ‘60s, I was in the Army three years. I’d thought about returning to northern Minnesota to join my father, who ran a furniture store and funeral home in Chisholm. I’m an “Iron Ranger.” After the military, I went on to the University of Minnesota Medical School. My training consisted of a residency in internal medicine, then oncology, and medical chief residency—six years total in Cincinnati, Ohio. It was there I met my wife, Dr. Jan Clarke.

Why oncology?

I enjoy the challenge of trying to cure cancer or “buy” people quality time in life or help them through the end of life, if that is their choice. The field involves a great deal of personal contact and science. As for being challenging, really, every field in medicine is challenging and not one is more so than another. All the fields involve patients who are sick and want to get better.

People have asked, “Is your occupation stressful?” I like to say that people become stressed over different things. I don’t find oncology stressful. Yet I couldn’t be a local police officer because of the stress, at least as I perceive that job. Everyone has an occupation in which they are comfortable.

Office practice in oncology is very satisfying because it involves working one-on-one with people. However, in my role today, I’m able to have a much greater influence on patient care and influence the experiences of many more patients, such as in improving safety or patient service.

Growing up, did you have a relative with cancer?

No. But I had in medical school a dear friend who developed leukemia. I was very involved in her care and that helped point me toward oncology.

I’ve been told by one of your staff that nearly everything at ISJ-Mayo revolves around its mission statement. What is your mission?

Our mission is simple. We are trying to provide care that is patient-centered, safe, effective, timely, efficient and equitable. Somebody once said our mission statement is “motherhood and apple pie,” but it’s really not. Healthcare for years and years has not been patient-centered—we’ve been much more doctor- or nurse-centered. Just one example: Why did we used to feed patients breakfast only at 7:30 a.m.? Because it was easiest for us. Our new way of doing it is meal on demand. We now ask the patient what they would like to eat and when they would like to eat. Of course, that means we have to adjust medication schedules and other tasks, but shouldn’t the patient be treated that way?

As for safe, healthcare certainly hasn’t been. The world is only coming to realize that healthcare is a phenomenally complex and dangerous industry. We’ve been on a mission at ISJ-Mayo the last few years to make it dramatically safer.

As for effective, we use the latest, known best practices.

Timely—patients are seen when they want to be seen.

Efficient—there is a great deal of waste in this industry. This is one reason healthcare costs so much. We are trying to drive out waste.

And equitable: A patient ought to at all levels get the same diabetes care in Waseca or Mankato as they receive in Rochester. Obviously, we haven’t got this down perfectly, but these are the goals we are working toward.

I would assume your soon-to-be heart and cancer centers are outgrowths of your mission statement. What do you see ISJ-Mayo doing the next ten years to further live out its mission?

Medicine will be exciting the next ten years as even more genetic research comes to fruition. The ability of researchers to fashion drugs to treat specific cancers will explode. So will our ability involving cardiac disease to prevent or change the outcome of heart attacks. We will be able to tell who is at risk for colon cancer and therefore who ought to have a colonoscopy, rather than test everyone. Fascinating developments are coming the next ten years.

How will these developments change our society?

First, having more information about people will present a number of new ethical dilemmas. For instance, I’d want to know if I’m at risk for colon cancer, but I don’t think I’d like my health insurance company to know. If we’re going to insure people, we as a society will have to figure out this potential problem. At the same time, we are going to find cures for diseases that have killed people in the past. That will be pretty exciting.

We will go through a period of change similar to what healthcare went through when antibiotics were first discovered in the ‘30 and ‘40s. There will be huge improvements.

There will be other ethical dilemmas. For instance, should your employer know you are at risk for colon cancer, and would he decide not to employ you if that were the case?

As for insurance: If finding out you don’t have any genetic markers for any major diseases, you shouldn’t be allowed to opt out of the insurance system—that is, if the system is going to survive. If the only people in the system are those at risk, then the cost would go through the roof. Everybody must be covered and contribute.

I’ve read where nurses at ISJ-Mayo have more autonomy to make individual patient decisions. Is that true? And why is more autonomy important?

Autonomy is a funny word. More and more healthcare now revolves around teamwork—letting people on a team make decisions in their areas of responsibility. For example, if an ISJ nurse has three very sick patients, and she says she can’t take care of a fourth, it’s important that we know that information. It’s also important we support his or her decision. Or if the nurse has four or five not terribly sick patients and he or she is able to handle another, great. But the key in this area is letting the nursing staffs say when they can and can’t deal with more patients. More and more, we deal with patients as outpatients—and more and more, those admitted to the hospital are really quite ill. We have to count on our front-line staff to tell us what they can and can’t handle.

Correct me if I’m wrong—you were appointed to the National Academies?

No. The Institute of Medicine is a subset of the National Academies. I was named to a study group of the Institute of Medicine that wrote a report about nursing and patient safety.

And when you were at Luther Midelfort in Wisconsin, again, you led efforts to improve nurse and patient safety. Could you detail some of those efforts? Including issues such as mandatory nurse overtime?

As for overtime, there is very clear evidence that working more than twelve hours is dangerous, probably as dangerous as being under the influence of alcohol. So mandatory nurse overtime, in time, is something really needing to go away, unless there is a clear and specific reason.

Such as a crisis?

Yes. For instance, if it snows heavily and people can’t get to work, and yet we still have patients to care for. But as a routine practice, mandatory nurse overtime should go away.

Other practices to improve patient safety? Here at ISJ we have put in place protocols so that anyone on a respirator is guaranteed to receive the proper five parts of care associated with that respirator. Due to that protocol, we at ISJ have reduced the number of people getting pneumonia from respirators from 14 a year to almost none. We have had only one case in the last two years plus. That is a dramatic improvement in safety.

We also have a process here called a “rapid response team.” For instance, the team might go into action when a nurse on the floor at three in the morning says she’s nervous about a particular patient. She can call an ICU nurse, who will look at the patient as well. If the patient is in trouble they can reach the physician. By doing this we have dramatically cut down on the number of patients having cardiac arrest on floor. Our goal is to sense changes in a patient early and intervene if that patient’s condition is deteriorating.

What about medication safety?

This is a huge problem all across the U.S., not just here. We know that we used to have the same number of medication errors everyone else had. The challenge with medication safety is figuring out which errors cause harm. For example, being late with a sleeping pill is an error, but it won’t cause harm. So we are trying to figure out which medication errors cause harm, why those errors happen, and we are trying to change the process in order to improve.

I see a potential problem: the more efficient and safe you become, the less money and profits you will be making.

No, I don’t believe that’s really the case. I really don’t believe that. Because if we…

I’m not being sarcastic with the question.

No, I think it’s a fair question. First, this industry has to get over making money from mistakes. Perfect example: If everyone’s blood thinners were in perfect control, we would have fewer admissions of patients with blood clots and bleeds. And that would be a good development for society. Even though we make money from blood clots and bleeds, we must get over that. However, on the flip side, patients getting ventilator-related pneumonia are often on Medicare and will spend a great deal of time in intensive care costing us money—and Medicare won’t pay extra for it. I passionately believe that by producing better and safer outcomes, we in fact will have lower costs overall and will make money. And we have to make money in order to stay in business.

Has Mayo implemented Six Sigma?

Parts of Mayo have, and we did. (Laughter.) Many techniques exist in our industry to help us become more efficient and safe. Six Sigma is a way of standardizing processes and it’s a large part of what we’ve done here to improve. Also within Mayo Health System, Fairmont Medical Center is using Six Sigma, and we used it with Mayo at Luther Midelfort Health System in Eau Claire, Wisconsin.

Is the relationship between ISJ-Mayo, Mankato Clinic and Orthopaedic & Fracture Clinic still strained?

When Mayo first came to town, significant animosity existed between Mankato Clinic, ISJ and OFC. In the last few years that relationship has improved significantly. OFC has superb physicians—in fact, they supply our orthopedic services. Mankato Clinic physicians also are outstanding. And it will take all of us to grow this regional medical center. All the patients will benefit; all the physicians will benefit.

So you think a rising tide lifts all boats?

Absolutely. And the patients benefit. A little competition makes us all better.

Changing gears: When you were at Luther Midelfort, prior to ISJ-Mayo, tell what you did to help Chippewa Valley Technical College (CVTC) meet a community need? Could something similar be done here?

Oh, yes. And we’re already doing it here. Back in Eau Claire (at Luther Midelfort), we worked with CVTC to provide onsite locations for much of their lab and x-ray training. We’re doing the same here with South Central College and others, providing onsite training laboratories. Most of this was going on before I came.

Is there more that can be done locally collaborating with colleges?

Sure. When in Bellingham, Washington, along with a large group of Mankatoans studying that city, we picked up a number of ideas that could involve our having more training and sites here. We have talked some about setting up a simulation laboratory. The educational institutions here are phenomenal and the closer we work together, the better we will all be. MSU and South Central College ought to be providing most of the new technicians needed here. The challenge is keeping them in this region. Most young people feel a need to go away from home for a while. That’s part of growing up. So they often will start here and then leave to a bigger city. We hope in time they will return home to settle down and raise a family.

Compare Mayo Clinic and Mayo Health System. And what is the relationship like between the two?

There are differences. Our role and mission within Mayo Health System is to provide care as close to home as possible, usually for the most common ailments. Mayo Clinic’s role is as a specialized, tertiary, research, and teaching and practice institution. For example, we will take care of diabetes and heart attacks here well. However, in my specialty of cancer, we don’t do bone marrow transplants here and likely won’t in the near future. So we send bone marrow and other types of transplants to Mayo Clinic in Rochester, which is a highly specialized institution with specifically trained people. Now, you and I could choose to drive to Rochester for routine care. That’s fine and they will see you. But their real expertise is in those highly specialized areas.

Mayo Clinic and Mayo Health System work closely, and have begun trading information and providing access to records back and forth, to make it easier to move patients. We work hand-in-glove. Our relationship with Rochester is such that physicians here are treated like Rochester staff when trying to get a patient into the Rochester system. I can refer you there just as if I were a Rochester physician. That benefits our patients.

Years ago, you were appointed to a special committee to explore the potential merger of United Wisconsin Services and Blue Cross/Blue Shield United of Wisconsin. What did you learn from that experience?

(Laughter.) United Wisconsin Services was a for-profit organization listed on the New York Stock Exchange. It was very interesting learning more of the business world. The value of that merger was we returned almost five hundred million dollars to the state of Wisconsin when we took Blue Cross public and sold it back. The money earned went to the two medical schools in that state. From that experience, I learned about the world of for-profit organizations, and big business, and healthcare from another point of view.

Anything surprise you?

No. But I’m convinced there are still many layers in our healthcare system, some of which are useful and others not. I don’t have a magic answer to the rising cost of healthcare except that there is still waste that needs taking out. Ultimately, we have to have people more involved in learning the costs associated with their healthcare.

What do you mean by that?

As we get higher deductibles, and health savings accounts, patients will finally start asking, What is this going to cost? One problem of our healthcare system now is that if nothing costs you anything, then you want everything. Once things start costing money, patients will start asking if a particular test or treatment will make a difference in their care. Suddenly, they are getting involved. For example, CAT scans are useful for headaches that have gone on a while and we don’t understand the cause. Doing a CAT scan on a headache someone has had only two days is an expensive way of treating it.

Isn’t there resistance to health savings accounts from some in the medical community because it will force them to become more competitive with pricing?

Yes, and that’s okay. As pricing improves, we’ll get better taking out waste. When someone pays you no matter what you do for a patient, then you don’t have to pay much attention to waste.

Remember, ISJ-Mayo is an employer also. We have several thousand employees, and we are paying their healthcare costs. So we also are interested in getting those costs down. And because our employees are paying a portion of those costs, they also want those costs to come down.

Think about colonoscopies. Right now the recommendation is that everyone over 50 should have one. If getting good enough with testing to know who is at real risk, so that only ten percent of people need that colonoscopy, we can save massive dollars. With prostate cancer, if we knew who was truly at risk, which meant who ought to have the invasive treatments, and knew the rest were going to have this disease but were not going to get in trouble with it. We would also save incredible amounts of dollars.

Are physicians losing decision-making powers in treating patients?

Most physicians are beginning to understand that as we work as teams, standardizing care in the long run will provide better patient outcomes, because by doing it we can look at results, compare and improve. Of course, care has to be standardized with the individual patient in mind. For example, we have diabetic patients in our hospital and now have an insulin protocol for those patients. If we all use the same protocol, it is much more likely that the nurses will get each patient’s care right than if we have 200 individual protocols. At the same time, as a physician, I’ve got to be willing and able to adjust that protocol slightly, if I know that my patient is very sensitive or resistant to insulin. But by standardizing that protocol, and getting it from several hundred down to one, which is then adjusted to the individual patient, we get better outcomes. Sometimes physicians call that a loss of autonomy. But most of us would say it’s doing best for everyone. In general, physicians are coming along with this process pretty well.

You are co-chair, along with Tami Paulsen of Paulsen Architects, of Envision 2020. First, what is it? And why is that process important?

Envision 2020 is exciting. I came to Greater Mankato in part because of the type of people working at ISJ and because this community likes to think ahead. Twenty years ago this community created ACT 2000 and came to a consensus about what the city should look like in twenty years. Now we’re repeating the process. A number of those issues discussed twenty years ago came about in due time: transportation planning, an industrial park, and Midwest Wireless Civic Center. All that happened, in part, because of what people did twenty years ago. This process of saying where should we be in twenty years by bringing together as many stakeholders as possible—it’s rare. There aren’t many places in the U.S. doing it. It says something about Mankato as a community, that it’s willing to invest the energy necessary. It’s an honor to be a co-chair because of all the exciting people involved.

If we want rail transportation to the Twin Cities, for instance, we have to be thinking now of where it should go, rather than in the future. If we want arts facilities, we have to figure out where, now.

ISJ-Mayo has an institutional overlay campus plan. What is it? And has it been frustrating to you to want to grow your campus and be totally surrounded by neighbors that don’t necessarily want to move?

First off, I don’t agree with the statement about our neighbors because the neighborhood has been very supportive. There are a couple of individuals that would like to keep everything the same. But the vast majority understands that the major medical campus is here and that we are going to grow. They have been supportive as long as we have been out there talking about what we want to do. And we are obligated to do that.

The overlay is a plan for how we would grow over the next 20-30 years. One might ideally say that wouldn’t it be great to move somewhere else. But the cost of that would be phenomenal. We are going to be here a long time. Parking garages are on the plan and within the overlay district. We have had a great deal of support from the community, city, and neighborhood.

Is southern Minnesota ready for bird flu?

Are we ready? Is there likely to be another flu epidemic of some type? That answer is strongly yes, given the growth of the world population and our modern ability to travel. The world has had epidemics over the years, including one in 1918. The odds are there will be another. The real challenge will be for all of us dealing with it on the front lines. We are working at it right now, like other health centers, on plans to be more ready. Our response will depend on what happens with the flu, its particular strain, who it attacks, and how it attacks.

What more can you do?

We have to have more conversations right now about the what ifs? We have to discuss the ethics of who gets vaccinated. And you can imagine how frightening it would be working at a medical organization during an epidemic. It’s all part of disaster planning, which we work hard at. Our state also has plans, and is one of the better states in planning. But, like President Bush’s report that went out recently, this is going to be a local issue, and we’re all going to have to deal with it locally. It depends on how big the threat is.

This is potentially a huge problem.

Yes.

Then how can you inoculate the public—and by inoculate I don’t mean giving shots, but giving people advance notice—to let them prepare now for potential problems.

You have to be careful about going overboard and creating panic. There aren’t many things we can do until the flu gets here. You can prepare the public by discussing things like hand washing and how to deal with social situations, but you can’t shut down the world. I heard someone the other day saying, “You have to keep essential services going, because if you don’t, the panic gets even bigger as the public looks around.” Talking about bird flu is good because then it won’t surprise anyone. In time we will get a flu epidemic; if not this year, then in ten years.

What happened to Dr. Rauf Subla?

Rauf has been in the U.S. ten years and is an ISJ-Mayo intensive care specialist married to an intensive care specialist. Earlier this year, he went to a meeting in Canada. When returning, U.S. Customs let his wife and family through but delayed his return for almost a month. He is a middle-aged Asian male, an Indian. The State Department had a lot of leeway in what they could do with him.

Of course, you didn’t have a contingency plan for that.

That’s something none of us had thought about. Fortunately, Sen. Coleman got on the telephone to the State Department and shook it loose. So Rauf is back. It shows how we as a society want to be safe, but boy; the bureaucracies sure can catch people and put them and their organizations in a bind. He was very important to our critical care service. Also, that showed the beauty of our relationship with Rochester. We have four intensive care physicians. If someone is sick or can’t get back from Canada, for instance, we have backup from Rochester.

How important is board certification? I’ve read where six in ten physicians have it.

It’s probably higher than that. Board certification is very important. It’s a measure of quality, though not the only one. The individual with it was able to pass certain examinations in their specialty to prove they had the knowledge and skill. But like all tests, it’s not perfect. It is an ongoing measure and people ought to be making sure their physicians are board certified.

Would they just ask them?

Just ask. The certification is probably framed on the wall in their office, but certainly they should ask them.

What about your relationship with your wife?

(Laughter.)

You met her in Cincinnati?

In 1976 when I was an intern at Cincinnati General Hospital and she was a cardiology trainee. We married two years later.

What attracted you to her?

She’s a very smart and beautiful lady. She’s caring and good at her job. We get along well together and have raised two wonderful children. We enjoy each other. As for her last name being different from mine—we were married after she earned her medical license. Only half-jokingly, to change your name at that point God has to come down to do it personally.

What is there about her that sets her apart as a cardiologist?

Like many women, she is a better listener. And she understands people. She’s an excellent technician and is outstanding doing cardiac catheterizations. But it comes back to the human side—she can get at what is really bothering people and understand what they are about. Women in general tend to do that better. She’s a very caring physician. She’s the kind I’d want if I were sick. We have hired two more women as cardiologists, and they are three of our seven total here. Our plan is to grow the total number of cardiologists to eleven to staff the new cardiac center.

Why build new heart and cancer centers? Were they planned long ago or was it brought about primarily by Lowell Andreas’ generous gift?

His gift jump-started the cancer center. About four years ago Mayo wanted us to become the regional medical center for southwestern Minnesota. That means not only becoming good at chronic and preventive care, but urgent and unusual care as well, which means cardiology and oncology. Two examples: Patients in oncology get both radiation therapy and chemotherapy, both of which tend to make people feel sick. To make people drive back and forth to Rochester for that therapy is a great inconvenience.

As for cardiology, there is clear evidence that for a patient developing a heart attack, the faster we can get the heart vessels opened the less damage that person will undergo. As a regional center, we can get patients in here quickly, get the vessel open, and dramatically reduce the amount of heart damage.

You have said that Mayo has divided up its Mayo Health System into three regions, and Mankato is the headquarters for the western third.

There is one regional medical center in northwestern Wisconsin around Eau Claire, based at Luther Midelfort. Another is in LaCrosse based around Franciscan Skemp Medical Center. The third is here in Mankato at ISJ. Thus, Mayo puts a lot of resources into this center to make it a regional provider. If not for this relationship, Mankato (and the region) would not have a number of medical services. If we weren’t servicing Springfield, Waseca, Le Sueur, and Fairmont, for instance, there’s no way we would also be able to support an interventional cardiologist. There wouldn’t be enough volume. By becoming a regional center, Mankato (and the region) gets care it wouldn’t have otherwise.

Living with Death

“Our family businesses began in Chisholm in 1905, so we all grew up in the funeral business. Bill’s grandfather handed it down. We lived with death our whole lives. Clarence got to know all these generations of people that kept coming in to the funeral home. He always would remember their names and family histories. He had a great personality for that.” —Glenn Rupp, 82, brother of Clarence and uncle of Dr. Bill Rupp, from a telephone interview.

Going His Own Way

“As a boy, Bill (Rupp) worked hard and was always eager to work. He never slacked off or sat around. We weren’t that disappointed when he chose not to join with us in our family business. He was a sharp kid, getting some education through the military. We never put pressure on him to join us, although his father at one time did think he might be going into the funeral business. “ — Glenn Rupp

Getting To Know You: Dr. Bill Rupp

Born: April 12, 1946.

Wife: Dr. Jan Clarke.

Education: Dartmouth College, and University of Minnesota Medical School.

Two children: Allison and Chris.

No I in Team

Nobody does this alone; it takes a dedicated team. It’s the frontline people that make things happen here (at ISJ-Mayo). —Dr. Bill Rupp.