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We’re on the cusp of a wave of capital investments the likes we’ve never seen. AI and generative AI have sparked an arms race, with every large tech company investing massive amounts of capital to build the necessary data centers and infrastructure. Goldman Sachs projects the amount invested to met data center demand will likely exceed $1 trillion by 2030. Bank of America has said the rewiring of global supply chains, leading to massive factory growth and redesigned logistics networks, will garner another $1 trillion. And according to the International Energy Agency, investments in clean energy and associated technologies necessary to reach net-zero-emissions goals will add even more to the tally, rising from $2 trillion today to an estimated $5 trillion by 2030.

Generative AI isn’t the strategic oracle many say it is. Like any other form of AI, it is a mirror that reflects patterns, trends, and decisions of the past. It cannot reliably break new ground or generate truly novel solutions given that it relies on pre-existing data and learned probabilities. But there are three ways leaders can leverage generative AI to support forward-looking decision-making that steer organizations toward growth and innovation: as a sounding board, to explore scenarios, and as an ideation tool. To effectively employ any AI in strategic decision-making, it is vitally important for managers and leaders to understand the limitations that are inherent in the way it generates output.

BRIAN KENNY: It’s hard to create a successful startup. Each year about 600,000 startups are launched in the US. 10% fail within the first year. 90% will fail within the first decade. And, in the medical technology field, survival is even harder because in addition to all the usual challenges of launching a firm, they also have to grapple with regulatory hurdles, clinical trials, capital intensity, and reimbursement issues. Facing all of that, it’s no wonder that few med tech ventures make it to late-stage development.

In this episode of Cold Call, we’ll talk about an innovation that’s helping to level the playing field for med tech startups and could hold promise for startups of all kinds.

Today, on Cold Call, we welcome Professor Regina Herzlinger and guest Duke Rohlen to discuss the case “Ajax Health: A New Model for Medical Technology and Innovation.” I’m your host, Brian Kenny, and you’re listening to Cold Call on the HBR Podcast network.

Professor Regi Herzlinger has been called the Godmother of Consumer-Driven Healthcare by Money Magazine and she wrote the book, Innovating in Healthcare: Creating Breakthrough Services, Products, and Business Models. Welcome back, Regi. It’s great to have you on the show.

REGINA HERZLINGER: Always a treat to be here, especially with Duke.

BRIAN KENNY: Yeah, and Duke Rohlen is the Founder, CEO, and Chairman of Ajax Health. He’s the protagonist in today’s case. He’s a graduate of Harvard Business School as well, going back a few years. We won’t date you there. Duke, great to have you on the show.

DUKE ROHLEN: It’s terrific to be here. Thank you.

BRIAN KENNY: I know that you’re here today on campus because the case is being discussed and you’re going to be… Did you already do it?

REGINA HERZLINGER: Yeah.

BRIAN KENNY: Okay. All right.

REGINA HERZLINGER: We’re late because students just mobbed us, right?

DUKE ROHLEN: That’s right.

REGINA HERZLINGER: As I said, I had to take him over my shoulder.

BRIAN KENNY: Drag him out of the classroom. For our listeners who aren’t familiar with this, one of the great things about Harvard Business School and being a student here is that many of the protagonists who we write cases about visit the classroom on the day the case is discussed, and they get to sit there and it might uncomfortable. Duke, you tell me and listen to the students talk about how they would make decisions that you had to make in real life. What’s that like?

DUKE ROHLEN: I love it. They’re very smart. They’re very engaged. They get most of it right. Sometimes they’re off, but there’s logic behind their being off. I’m always amazed at how much better they are at thinking through things real time over a night of reading versus me having to live it real time and figure it out and go through all the mistakes as I make it happen.

REGINA HERZLINGER: I think another great thing is seeing Duke. So, you read about this and who could Duke be. Duke shows up and he’s full of energy and passion about the field. He’s enormously successful, but he tells you, “I’ve almost failed in everything I’ve done.” So, he gives them not only a great model, but a lot of courage.

BRIAN KENNY: It humanizes the case and that’s part of the reason we do Cold Call is because we want people to hear what the protagonist experienced. We want to hear the faculty member talk about why they decided to write a particular case and why it makes for a lasting set of insights for managers. So, Regi, I’m going to start with you. I want to know what initially caught your attention about Ajax Health and why you decided to write a case about it. Why was it important to you to document this?

REGINA HERZLINGER: So healthcare is very oligopolies. It’s more and more consisting of very large firms and it’s hard to break into those firms. It’s also very hard to innovate in those firms. So, I was on the board of a huge pharmaceutical company that was the first to commercialize interferon. The CEO of the company was a lawyer who knew very little science, but he thought if he commercialized a new product within his existing firm, the existing firm would kill it. What he did is he started a whole separate firm, secret firm that reported only about interferon.

I have two more cases with exactly the same thing. CEO of very large company to get an innovation that’s not going to be killed by the “not invented here” mentality has to break off and start a new firm to do it. Ajax, Duke’s model, is a brilliant way of dealing with the lack of innovation in big companies, especially big healthcare companies.

BRIAN KENNY: Duke, let me turn to you for a minute. You were new to healthcare. In fact, when you came to HBS, you said that you hadn’t been in the field at all. Can you talk a little bit about what those early days were like at HBS for you and why you decided that this was something you wanted to pursue?

DUKE ROHLEN: So I graduated from Stanford and I couldn’t get a job and decided to start a restaurant business with a friend of mine who was graduating from Stanford Business School. The restaurant was successful. We opened it in Palo Alto. We ended up opening up nine more. After about two years, I realized that, gosh, I like running businesses and I like the entrepreneurial spirit and all of the intensity that comes with that, but I definitely didn’t want to make a career in restaurants. That reached a pivot point when I was offered the job as the CEO of Sizzler and I turned that down and instead opted to go back to Harvard Business School, but I went back to Harvard Business School with a mandate to transition to another industry.

My thought was that I’d become pretty good at managing chefs who typically think they’re the smartest people in the room. It’s not unlike doctors who are the smartest people in the room. So, I thought if I could manage chefs effectively, I could potentially manage doctors. Then I was lucky enough to get into Regi’s class, and in Regi’s class, I was exposed to not only doctors, but actually how businesses in healthcare are run. What I did actually my second year of business school was to take a job in California, working for a startup. So, I would fly back to California each week and then fly back on the red-eye Sunday night. It was a crazy, crazy year, but it really kick-started my exposure and my ability to get into the healthcare space and then it all went from there. I’ve been in the healthcare business running med tech companies ever since.

BRIAN KENNY: Yeah. You’ve had a lot of different success with different kinds of startups in the med tech space. At some point, you came into this notion of the growth drivers and the chassis model. Can you describe that for us because that’s the central theme of the case? That’s what we’re going to be spending most of our time talking about.

DUKE ROHLEN: Yeah. So, the five companies I’d run previous to doing the Cordis deal, which really is at the cornerstone, it’s the core of what the middle path is about, were beset with risk. I was telling Regi’s class earlier today that each company I ran, there was a point when it could have failed or succeeded. The real challenge with that was not knowing that we could have a buyer, not knowing that we could actually commercialize this technology. The medical device space is really challenged by huge capital requirements, long development timelines. You have to get regulatory approval before you can start selling and commercializing. The venture model is typically operating on a four to five-year cycle, and the life line for these med tech companies is like nine years.

So, it doesn’t really fit into a category. So, what I came up with is this idea that instead of trying to opportunistically build a technology that you would hope someone would want to acquire, we would buy the company that needed technologies and in this case that we profile in the HBR article, it’s Cordis. And then we would really do an assessment of what the technology deficiencies in the portfolio were. Then we would underwrite to develop those technologies for Cordis.

Through that orchestration of having what I call the chassis, which is the commercial engine that can commercialize the assets and the growth driver engine, which is what’s creating the products, you create this combustion where you can get a lot of people developing technologies for an engine that really needs growth, put them in, and completely transform a company.

BRIAN KENNY: By the way, I love the car metaphor. It’s very American. It’s very relatable.

DUKE ROHLEN: Yeah.

BRIAN KENNY: Regi, let me turn to you for a second. You’ve been looking and studying innovation in the healthcare space for many years. Why is it so hard to innovate in this space?

REGINA HERZLINGER: Well, it’s hard because medicine is hard. So, if you’re going to innovate in healthcare, it’s not like some other industries. You have to know an enormous amount about medicine, have to know not just what your body looks like, but just have to know what the different functions of different organs, what the problems are, what kinds of solutions people are looking at. It’s enormously difficult. Then you have to know who practices medicine, what are these physicians, nurses, the therapists, what do they like? It’s a very, very unusual group of people, tremendously intelligent. How do you motivate them to change?

Healthcare is very heavily regulated; regulated by the Food and Drug administration. Very good thing. I love the Food and Drug Administration, but it takes millions, tens of millions, hundreds of millions of dollars to get through their requirements. Healthcare is not a consumer industry. It’s paid by what are called third parties. Somebody else is paying for our healthcare. In this case, in your case, in my case, the Harvard Business School. In your case, Duke, I’m not sure.

DUKE ROHLEN: It’s Ajax.

REGINA HERZLINGER: So you don’t have the normal consumer interaction of saying, “I like this,” or “I don’t like that.” You have the third party making the decision. The innovator has to convince this third party of three things. One is that they want to pay for whatever the innovation is. So, these drugs, these miraculous drugs that are dealing with people who are morbidly obese, many insurance companies are not sure that it is insurable, that it is a medical problem that deserves insurance. Convincing this third party that your innovation should be insurable and these drugs costs hundreds of thousands of dollars a year have to be insured. Then the physician or whoever is prescribing the drug needs a code. To get the code, the innovator has to wander through the key opinion leaders, make sure that they get the right code. So that whoever’s prescribing or using the thing can code it correctly and get paid for it. How much do you get paid? There’s another question. How much does the insurer want to pay you?

In the UK, they have a technique. It’s called the quality adjusted life year. They judge how many quality adjusted life years are added by the innovation and is the price that the innovator wants worth the addition in quality adjusted life years. How we reach payment decisions in the US, be damned if I know. But, it’s a tough industry and it’s tough because there’s so much particular knowledge that people have to have in order to be effective in the industry.

BRIAN KENNY: Yeah. You mentioned earlier during the introduction that what they’re doing at Ajax is brilliant. What makes it brilliant? What are they doing to deal with some of the things that you just talked about?

REGINA HERZLINGER: The brilliance of Ajax is that it enables these extraordinary people, the scientists, the engineers with their imagination about how healthcare can be made better and cheaper, and gets rid of all these operational details, which are very, very important.

Second innovation that I thought was so smart, really because of Duke’s personality and his experience, he did something amazing. That is he enabled private equity, not a VC, but big money, put in $1.3 billion dollars…

BRIAN KENNY: That’s a big number.

REGINA HERZLINGER: … right off the bat. So, that he and the engineers and this whole team didn’t have to repeatedly go back and ask for $10 million, $20 million, $50 million, $100 million. They could concentrate on what they did. Well, I think it’s a model that should be used in other industries. I’m so glad he used it in healthcare.

BRIAN KENNY: I want to come back to that in a little bit, but let me turn to you, Duke. What Reggie’s describing sounds so daunting. I can’t believe that anybody did it in healthcare at all. We’ve heard about some of these issues. How did you see beyond that and create the model that you’re using with Cordis? Maybe just for our listeners, describe Cordis, describe that acquisition and why it made sense.

DUKE ROHLEN: Sure. So, at the highest level, what I have tried to do is with each successive company, institutionalize lessons learned and core ideas and core capabilities that I did well. So, that each company, I’ve been successfully a little bit better. Through the course of five companies starting, growing, and then selling them, there were a couple common denominators that I knew I had to avoid. One is capital. Like Reggie said, it’s really, really tough to go with a venture model every two years with your handout. It’s distracting for the organization because you’re worried more about trying to get the capital than you are about executing on the program. It’s really tough for the original investors because the next set of investors are always trying to push down the value.

It’s a broken system in healthcare where the lifeline of a company requires hundreds of millions of dollars potentially and the timelines are long. So, what we did with Cordis is we bought a company that was really broken. We carved it out of Cardinal Health. What we liked about it was that it had no growth, it had no EDITBA, it had a really messed up distribution system. It was ugly. That was compelling to me because my feeling and my vision is that the value of the technologies, which I call growth drivers that I’ve created, have transformed the profile of the companies that have acquired my technology. We put a growth driver into a company that’s not growing, and all of a sudden, that company blossoms.

So, the vision for Cordis is we could do that at scale. We could take a company that had $700 million or so of sales, wasn’t growing, and we could transform that company by bringing innovation. So, we created a separate innovation engine that we call Cordis-X with $300 million to really in a bespoke way figure out which technologies the portfolio needed and then build them, leveraging an ecosystem like Regi referred to. That’s not unlike app developers in the App Store. App developers are developing apps and they know the commercial engine is the Apple App Store. That’s the same as our model.

We have engineers that are out there developing technologies, and our app store is Cordis. It has completely transformed the company and transformed in many ways the way that growth and innovation can come into stagnant companies that need it. Quite frankly, growth is what drives value in these companies more than in technology, more than in biotech. It is literally top-line growth.

BRIAN KENNY: Can you give us a specific example of a growth driver? What’s a growth driver that you would plug into a company and how does it manifest in the chassis? How does it get moved through that chassis?

DUKE ROHLEN: So the growth drivers are not always transformative technologies. In the middle path to innovation, we talk about on the one hand you have iterative technologies, which are changing a color, making it a little bit bigger. On the other end of the spectrum, you have transformative. What we did at Cordis-X is come up with a whole basket. On the one hand, we had transformative technologies like a drug-coated balloon that’s based on sirolimus. This is next generation drug-coated balloon.

On the other hand, we have a sheath. So, we have 16 of these products that are coming in. When you’re a $700 million company that’s looking to grow 10%, you don’t need a ton of revenue in order to change the profile dramatically. We’ll get it with the transformative. We’ll get some of the modest growth with the iterative, and then there’s a whole basket in between. So, that’s how we look at it. We look at it from a portfolio perspective.

BRIAN KENNY: Regi, Duke is making this sound simple. We do this and we plug that in and it flourishes. I’m sure it’s not that simple. How challenging is it to take an innovation like this and plug it into an existing infrastructure where there are silos, and they’re used to doing things in a particular way and they’re part of their own barrier to innovation?

REGINA HERZLINGER: Yeah. I think it’s incredibly difficult, especially in a company that in a way was the star of its particular industry, Cordis. It was owned by a distributor, Cardinal, which was started by an HBS grad. Cardinal grew under his leadership from $100 million to $225 billion.

BRIAN KENNY: You’re doing something right.

REGINA HERZLINGER: But once you’re $225 billion, how much faster can you grow? So they went into the medical technology business. Brilliant as they were, medical technology, it’s a very hard business. So, when Duke bought Cordis, fixing up Cordis was a huge undertaking. He can speak to it better than I, but I’m sure there was a great turnover in personnel, not in a cruel way, and also a change in spirit, in the idea that we’re going to be successful. We’re not just going to survive. We’re going to be a success.

BRIAN KENNY: What is that cultural situation like, Duke?

DUKE ROHLEN: So what’s really interesting is everything that I do is founded and the foundation of what I do is based on mentality. So, my mentality and the people and the teams that I work with are super-fast, super hungry, driven. Think of them as Navy SEALs and then think of a big organization like the US Army. The challenge is how do you influence an organization from a mentality standpoint, so they start thinking competitively as opposed to thinking about just maintaining the status quo? It was something that I did not expect. When we bought Cordis, we needed to turbocharge the chassis. We needed to overhaul the mentality.

We needed to change a company that had not had growth to thinking about not only growing, but how could we actually own and win in the category of cardiovascular and peripheral vascular medicine? So the way you do that is by leading. It’s by not only being a leader yourself, but also by finding people that are like-minded that have an ambition and a drive to radically change an organization and then empowering them. It sounds so simple, but it’s really hard. People have personalities, people have experiences. They’re entrenched in their ideas, and you give them a chance. If they’re not willing to embrace the change, then you have to get rid of them.

We overhauled, to Regi’s point, almost the entire leadership team at Cordis, not because they weren’t talented, smart, capable people, but because what we were going to do and undertake to do with Cordis, which is transition it to a high growth company in a short period of time, was going to take an enormous amount of energy, an enormous amount of commitment. People in their lives are either ready for that or they’re not. If they’re not, then they need to go someplace else. I think the hardest thing about Cordis was actually that.

It was not creating the growth driver engine. It was actually changing the mentality of the chassis of Cordis and optimizing it to be able to be ready to take on the products that were going and have now successfully brought into the organization.

BRIAN KENNY: Regi, in your experience at looking at this innovation in other places, how do you do what Duke is describing without demoralizing the people that have been there for a long time and put their heart and soul into this place and they feel like their work has gone for naught?

REGINA HERZLINGER: Well, there aren’t many models like this. To indicate the caliber of the people that Duke brought in, his general counsel, his chief lawyer was a clerk for the chief justice of the Supreme Court. So, they’re extraordinary people. How do you get rid of people who don’t fit in with the new model? I wish I could tell you how you do that gracefully. I’m sure they were well paid, their past accomplishments were well-recognized, but it still must be very painful. What do you do to relieve that pain? I wish I knew.

BRIAN KENNY: Yeah. But what this does do, I would imagine, is opens up the door for innovation in a new and exciting way. So, people see and feel that change is coming. I’m wondering if in your mind, is the portfolio model that Duke is describing where they’re looking across a whole range of things from modest innovation to extreme innovation, does that create new opportunity? The app metaphor that you used earlier for app developers or product developers, now they’ve got access to something they might never have had access to before.

REGINA HERZLINGER: For sure. So, I have another case study. It’s about a company called Sword, and Sword is an AI-enabled company for physical therapy. The CEO is like Duke, kind of a techie, and with a similar personality, very high-energy, charismatic personality. He got interested in pelvic issues that women have, inflammation, continually urinary tract infections, and he developed a terrific device called Bloom. He adopted Duke’s model and he has formed something like Cordis, a sales and operating company. He has 10 divisions under it that deal with different aspects, different innovations that use AI, sensors, and different kinds of therapists to deal with the problem. I’m sure that this model, whether it follows exactly the Duke model of buying a famous but tired company or taking an existing company and breaking it up so that you have these separate accelerators that are guarded from things that innovative engineers or doctors don’t like to do. I think it’ll take over the industry.

BRIAN KENNY: Duke, let me ask you, so we will go back to Cordis, that example. You’ve got a portfolio of devices that you’re putting into the marketplace. You’ve got your chassis that’s fired up and ready to bring these to market and deal with all the regulatory issues and other things. Do the folks who are in the chassis side of the business, do they have to know about all those things or do you have specialists where one group is representing one piece of the portfolio and another is doing another piece?

DUKE ROHLEN: I believe in transparent and open communication. So, it aligns to a vision that we’re all trying to affect towards. So, everybody knows what we’re doing. Not everybody’s responsible for everything, but in a company that’s got $700, $800, $900 million in sales, which is represented in over 50 countries and with 5,000 products, not everybody can be involved in everything, but there are four or five drivers, which we call the key drivers of the organization that everybody’s oriented to. What everybody in the organization knows is how they on a daily basis tie into one of those drivers and one of those four or five drivers, there’s actually five, is innovation and growth. So, they know what’s being developed.

They know when it’s going to be developed, and the engine of Cordis-X is inspirational and the mentality of the organization is completely transformed based on this vision that we can actually have new products, have new growth, not be reliant on either M&A, which is the way transformative technologies are usually brought into organizations or through internal R&D, which is usually 4 or 5% of revenue. We’re spending $300 million on a company that’s doing $900 million in sales. So, the amount of innovation that we’re able to bring into that company is transformational and everybody gets that. So, I want everybody to know that.

BRIAN KENNY: Yeah. Regi, you talked about Duke’s charisma. It’s pretty evident to me. How important is his leadership to the success of this model? Can you replicate a model like this without a leader like Duke?

REGINA HERZLINGER: So, no, the charisma is important. I think the competence is as important and the energy. I wouldn’t do this. This isn’t easy. It’s very, very difficult to do. The mission-driven, it’s healthcare. It’s about people’s lives, making their lives better, making it more accessible. So, there are other qualities that are very important that differ from those that Duke has.

BRIAN KENNY: Yeah, that’s an easy mission to get behind. Duke, let me ask you, is it easier to manage the chassis or the growth engine?

DUKE ROHLEN: I don’t manage the chassis anymore. I have an amazing CEO who I’ve worked with in the past, and he manages the chassis. I manage the growth drivers, and then collectively, we sit over both companies. My personality is driven by pace. I like to move very quickly. I like people that move very quickly. We try and get done in five days what larger companies do in two months, and it works for me. So, I really love the fast-paced organization of the Cordis-X. I will say though that the transformation that’s occurred not only with the incumbent people that have stayed at Cordis, but also with the new people that have come in, Cordis is now a rocketship. If I were to step back and say what the biggest learnings are, I would say one is that fixing a chassis that has not been optimized is really tough.

Two, blending cultures between a fast-paced culture, which we had at Cordis-X, and a slower paced culture at Cordis is really tough. But then third, the biggest learning that I have is how a smaller group of people, the leadership team at Cordis and the leadership team and the implementers at Cordis-X can actually wag the tail of a huge dog. It’s maybe the thing I’m the most proud of is how we have changed the mentality and the expectations of success for a company that didn’t really have them when we bought that company four years ago. It’s really remarkable and it’s profoundly influenced what I want to do for the next 20 years of my life, which is help people learn how to transform organizations and innovate in healthcare.

BRIAN KENNY: Regi, you mentioned earlier that you think this could have application beyond the healthcare industry. We actually did a podcast about innovation within the armed forces a while back within the Department of Defense. They did what you described earlier, which is they created a separate organization and it was like a “Skunk Works” thing. They were trying to infiltrate, penetrate the amazing bureaucracy of the Department of Defense. Not easy. I’m wondering if you think a model like this could work either in a setting like that or in some other industry where innovation is just really hard to achieve because of regulation or whatever the other kinds of hurdles are.

REGINA HERZLINGER: For sure. In our article, we cite defense as an area that could benefit from this model.

BRIAN KENNY: We didn’t even set that up.

REGINA HERZLINGER: I’m so happy to hear that something like that is happening, especially in this terrifying period of time that we’re in. But we also think that an industry like the entertainment industry, which increasingly consists of reruns of shows that I saw and that the reruns are things I didn’t much enjoy to begin with, but the imagination is so impoverished. Interesting entertainment rarely comes along. I think horror is among the most successful. Maybe it’s a reflection of the times we live in or for some other reasons.

But the Studio Universal struck a deal with a very small firm that makes horror films and it’s analogous to what Duke did with Cordis and with these accelerators. The maker of the horror films is tremendously successful. One reason for it is he’s very creative about making these films, but he’s free from financing them, from distributing them, from doing the onerous, the things that are not necessarily onerous, but that are onerous to a creative personality like that. So, we think two very important industries, which are kind of laggards, the defense industry and the entertainment industry, could easily benefit from the same model.

BRIAN KENNY: This has been a great conversation as I knew it would be. I’ve got one question left for each of you before we go, and I’ll start with you, Duke. I give Regi the last word because she wrote the case.

DUKE ROHLEN: Always, always.

REGINA HERZLINGER: He is a gentleman.

DUKE ROHLEN: Always. I give Regi the last word and the first word. So, happy to be first and let her be second.

BRIAN KENNY: You gave us a little glimpse of this. You talked about what you’re hoping to do now that you’ve got this model codified in a way that you think could be replicable. What does success look like five years down the road for Cordis and for your ability to be able to take this now and maybe apply it in some other places like Regi just described?

DUKE ROHLEN: I think the model will evolve. The cornerstone of my career has been evolution, right, thinking about what has worked and what hasn’t worked could be optimized for the next time you go around. What I’m really inspired by and what I work a lot with is younger people who really have a passion for healthcare and want to be in this space and don’t really know how to do it. They’re all bringing the energy that Regi was talking about. Energy trumps everything in my opinion, because you’ll run through walls if you don’t run tired. So, I’m focused on continuing to evolve the Cordis model. We’re applying it to companies that actually we’re not acquiring.

So, we bought Cordis and owned Cordis-X, but there are dozens and dozens of large med tech companies that need innovation that don’t want to sell their company, but they want to create divisional growth. So, we’re evolving the Cordis-X model to those companies. That’s what we’re doing. We’ve just raised a billion dollars to be able to do that. But the real fire in my belly, the thing that I love is trying to take on what Regi did for me, which is the role-modelship and the mentorship and trying provide that to a next generation of really bright people that will trump me in terms of the outcomes and the benefit that they’ll have on this space. So, that’s what I’m driven by now.

BRIAN KENNY: That’s great. Regi, you have focused your whole career on healthcare innovation. I know that you’ve been frustrated at the pace at which innovation can occur within the industry for all the reasons you cited earlier. Do you really see this as a game changer that could remake the ability for people to innovate in the healthcare space in the next five or 10 years?

REGINA HERZLINGER: That’s why I’m here. That’s why I got in touch with you, Brian. I think it’s a tremendous innovation. But in addition to that, this is the golden era of technology in medicine. The recent winners of Nobel in medicine, you’ll be glad I’m not going to describe it, but it’ll transform how drugs are made to be personalized to your particular structure and my particular structure. The development in the AI and the ability to understand better how medicine can be delivered in a more standardized and efficient way, huge opportunity. Medicine is very inefficient. Every expert in the field has said that at least a third of it could be cut out. That’s a third of $4 trillion dollars, a substantial sum. I think it’s just a wonderful time to be in the field.

Finally, I’m so glad I’ve lived so long because I think this is the time where innovation will be happening. What do I mean by innovation? It will be better, it will be cheaper, it will be more accessible. We still have 23 million people in the US who don’t have health insurance despite Obamacare and tens of billions all over the world. I think we’re going to see a change in that. Ajax is an example of a model that can make healthcare so much more efficient.

BRIAN KENNY: On that optimistic note, Regi, Duke, thank you for joining me on Cold Call.

REGINA HERZLINGER: Always a pleasure.

DUKE ROHLEN: Thank you very much.

BRIAN KENNY: If you enjoy Cold Call, you might like our other podcasts: After Hours, Climate Rising, Deep Purpose, IdeaCast, Managing the Future of Work, Skydeck, Think Big, Buy Small, and Women at Work. Find them on Apple, Spotify, or wherever you listen. And if you could take a minute to rate and review us, we’d be grateful. If you have any suggestions or just want to say hello, we want to hear from you, email us at coldcall@hbs.edu. Thanks again for joining us, I’m your host Brian Kenny, and you’ve been listening to Cold Call, an official podcast of Harvard Business School and part of the HBR Podcast Network.

HANNAH BATES: Welcome to HBR on Leadership, case studies and conversations with the world’s top business and management experts, hand-selected to help you unlock the best in those around you.

What makes a leader truly effective? Is it about strategic vision, time management, decision making confidence?

Robert Kaplan says the best leaders are exceptionally good at asking tough questions so they can make the right decisions.

Kaplan is the author of the book What to Ask the Person in the Mirror: Critical Questions for Becoming a More Effective Leader and Reaching Your Potential. 

In this episode, you’ll learn how to frame better questions to help you get the answers you need to make decisions. You’ll also learn how to use questions to clarify your four key priorities…and then make sure you’re spending your time in service of them.

This episode originally aired on HBR IdeaCast in August 2011. And just a note—we recorded this by phone. While the audio quality is not great, the conversation is. I think you’ll enjoy it. Here it is.

SARAH GREEN: Welcome to the HBR IdeaCast from Harvard Business Review. I’m Sarah Green. Today we’re talking about leadership, which is a familiar topic. But we’re talking about it in a slightly different way.

I’m talking today with Robert Kaplan, Harvard Business School professor and author of the new book, What To Ask The Person In The Mirror: Critical Questions For Becoming A More Effective Leader And Reaching Your Potential. Rob, thanks so much for talking with us.

ROBERT KAPLAN: Thank you for having me.

SARAH GREEN: So I think what’s interesting and different about this book is that it’s framed around questions. And so many books in this genre seem to be focused on providing answers. Why did you take that different approach?

ROBERT KAPLAN: Well, the reason I did this is, I’ve managed businesses and I’ve worked with so many leaders over the years. And ultimately when I go back and postmortem and think about what I should be doing in running businesses and nonprofits, and I sit with leaders in my office, or in their office, and talk through the issues they’re facing, ultimately it gets down to questions.

And I think through the most effective leaders that I’ve ever worked with that I learned the most from and that were outstanding, and they were very good at asking questions.

And what I’ve realized is the same types of questions come up over and over again. And normally to the point that, when someone is having a problem in a certain part of their business or nonprofit, their problem may not actually be what they think their problem is. Or the problem they’re having is a symptom. It’s not the cause. And ultimately when you’re having a problem or you’re frustrated or things are not going well, I found it is far more effective to step back and ask certain questions.

SARAH GREEN: In the book, you also have a set of questions that would be useful for leaders at any level, and very specific things about something as seemingly small as managing time. That’s something that almost all of us struggle with. So can we get a little specific and talk about maybe, how would you use questions to help manage your time?

ROBERT KAPLAN: OK. So in fact, let me go through a little bit of the setup. There are eight chapters, which basically, eight areas of questions. There’s the big what seems like a macro question, which is really a strategic question. What’s our vision and what are our key priorities? And what the chapter goes through is lots of different ways to help people figure out how to ask and answer those questions, and then how to put it into practice.

And what happens is we go from the big, as you say macro, strategic, down to the micro including, do you know your own strengths and weaknesses? Do you know your own passion? Do you match how you spend your time with your key priorities? Do you even know how you spend your time?

And, for example, you ask about time, most people may have a clear vision in priorities. But it doesn’t occur to them that they actually should track– let’s say you work 60 hours a week, for example. Break down those 60 hours. And I say to some people, measure it. See for a week how you’re spending your time. Then compare that break down to your top four priorities that you said are the most important things you and the business need to be doing. And almost invariably, when a manager or a leader’s struggling, there’s a mismatch, sometime severe.

And just think about it. I’m a professor at Harvard. Well, OK, what are the three most important things I need to focus on to be a successful professor at Harvard? OK, am I doing them? Well, no, not quite and not always. And why does that happen? Especially when you’re a leader. I’ve got people at my door. There’s a crisis that comes up. I have some old habits that– gee, the CEO always did X, Y, and Z. So that’s what I’m always going to do, even though it doesn’t fit the priorities anymore. I’m out of date. Maybe I’ve just gotten into some bad habits.

So what I’m trying to do is jar people. Sometimes asking a question will jar you. And if I say to someone, or I say to you or myself, does my time match the priorities? And I actually make myself go through it. I go, oh boy. And when I meet with the CEO and they just take me through it, I don’t need to say a word. They say, oops.

And then I’ll say, well, why are you spending 15 hours a week on X, Y, or Z? The truth is right. I never thought about it. I don’t know. It’s what I’ve always done. We were a small business once. And I always did this when we were small, and I never stopped doing that when we got bigger. And so what it allows people to do is say, you know what? I need to adapt. I need to change. It’s like, the light bulb goes on. And then they learn, OK, I need to strive to do this.

And by the way, you may go for several months where you’ve got a good match. And then all of a sudden the world changes again. And maybe you need to be out more with customers, and you haven’t made the adjustment. You just haven’t done it. I need to spend more time out with customers. And, boy, if I measure my time, I realize I’m spending almost no time. I knew I wasn’t spending enough time, but I didn’t realize it was so little.

And then you realize you got a problem with all your people where they’re watching you. You’re telling them to go out with customers, except you’re not doing it. And so there’s one chapter here on what signals do you send. Are you a role model? Because leaders are, ultimately, do lots of things. One of them is, you’re a role model.

People will imitate you. And so if you’re not asking these questions and trying to drive these issues, my guess is people are going to mimic you. And then you get out of alignment. So there’s a chapter also in this book on clean sheet of paper.

SARAH GREEN: What do you mean by that when you say clean sheet of paper?

ROBERT KAPLAN: And this sounds so innocuous. By the way, all the questions in this book– you talk about low tech. These are brutally simple questions, very plain, simple. No highfalutin questions here. They’re very basic. So one of them is, do you look at your business with a clean sheet of paper and decide whether what you’re doing still works?

And one way to ask this question is if– let’s say we’re starting over from scratch. Is this really the way I would organize this company? Are these the people I would hire? Are these the tasks we would do? Are these the markets we would serve? And this sounds like a very simple question. And most leaders, including me, often don’t do that. And why? It’s emotionally, extraordinarily difficult to do.

I’m running a business. I’m comfortable with the way I’m running it. I’m comfortable with our setup. I’ve gotten in a routine. And this requires me to take a step back and face some tough realities. And because it is so emotionally difficult to do, the best advice I give to many CEOs– and I used to follow this myself– take a group of three or four of your up and coming people. There’s a chapter on succession, planning.

Take some of your up and coming people, future leaders. Give them this assignment. Take yourself out of it. Give them this assignment. Ask them to do this analysis. If they had to start the business from scratch, how would they design it? And they’re not so emotionally tied to it the same way we might be. And then tell them in advance, I may not take all your advice. But I want to hear your recommendations.

And they will come back invariably, when I’ve seen this done, fabulous, fabulous insights. And sometimes it makes it easier for the leader to realize, you know what? There’s more buy in than I thought for this. People at the point of attack, close to the customers see this, and we actually need to try to do some of these things. That’s what I mean by the looking at the business with a clean sheet of paper. We invariably do this.

Listen, people who are successful, individually and who run organizations, have to ultimately look at reality, compare it to what they’re doing. And if you’re a business leader, you’ve got to do it. And if you don’t do this, ultimately the market will do it for you. It’ll put you out of business. Or your board’ll do it for you.

SARAH GREEN: And of course that means that the leader has to be more on his or her toes as well.

ROBERT KAPLAN: It does. But you know, a lot of people think, and we’ve had some government leaders, very famous leaders, who say, leadership is about saying, we’re going to go north northeast and follow me. And here’s what we’re going to do. And that’s what my people expect of me. And they don’t want to see vulnerability. They want to see confidence. And they want to see me make decisions. They come to me for the answers.

And I actually don’t think that that is necessarily– there’s some of that, that a strong leader needs to do. But I think a extremely strong leader, ultimately a very strong leader, is willing to stop and say, I don’t have all the answers, actually. I’m concerned about the fall and I want to frame a question. Let’s discuss it.

And so one thing, nice thing, that does for the leader is, you actually don’t have to know everything, which you’re not going to anyhow. And you don’t have to pretend you do. And it takes a great burden off people to know that.

And number two, rather than spending your time thinking of the answer, maybe a better use of your time is to think about, gee, are there two or three questions I should be asking, and how should we orchestrate a discussion so that we can actually figure out together what the best thing is to do? And we’re going to come up with a better answer and a solution, a plan of action, than if I try to do this myself.

It reorients the focus of the leader, takes a burden off that leader. But also requires a different type of preparation, as you say, being on your toes. A different way of being on your toes.

SARAH GREEN: So I guess the central point there is that if you’re not asking good questions, you’re never going to get good answers.

ROBERT KAPLAN: No. Listen. Part of being a leader is there’s deciding what you believe and acting on it. That’s part of a leader also is, to your point, is learning to frame, get better at framing issues, and asking questions, and orchestrating debate, and listening. All the things I just talked about require listening.

And that’s one of the most powerful tools and assets you have as a leader is listening. Asking a question and then listening. It shows a lot of respect to someone. If I ask them a question and I listen carefully what they say, it’s a very powerful tool that a leader has. And it’s underused.

SARAH GREEN: I think it’s some great food for thought. Rob, thanks so much for talking with us today.

ROBERT KAPLAN: All right, thank you.

HANNAH BATES: That was Robert Kaplan in conversation with Sarah Green on HBR IdeaCast. Kaplan is a senior fellow and professor emeritus at Harvard Business School. He’s also the author of the book What to Ask the Person in the Mirror: Critical Questions for Becoming a More Effective Leader and Reaching Your Potential.

We’ll be back next Wednesday with another hand-picked conversation about leadership from Harvard Business Review. If you found this episode helpful, share it with your friends and colleagues, and follow our show on Apple Podcasts, Spotify, or wherever you get your podcasts. While you’re there, be sure to leave us a review.

When you’re ready for more podcasts, articles, case studies, books, and videos with the world’s top business and management experts, find it all at HBR.org.

This episode was produced by Anne Saini and me, Hannah Bates. Ian Fox is our editor. Music by Coma Media. Special thanks to Maureen Hoch, Nicole Smith, Erica Truxler, Ramsey Khabbaz, Anne Bartholomew, and you – our listener. See you next week.

From the early days of mechanical automatons to more recent conversational bots, scientists and engineers have dreamed of a future where AI systems can work and act intelligently and independently. Recent advances in agentic AI bring that autonomous future a step closer to reality. With their supercharged reasoning and execution capabilities, agentic AI systems promise to transform many aspects of human-machine collaboration. The agentic AI prize could be great, with the promise of greater productivity, innovation and insights for the human workforce. But so, too, are the risks: the potential for bias, mistakes, and inappropriate use. Early action by business and government leaders now will help set the right course for agentic AI development, so that its benefits can be achieved safely and fairly.

HANNAH BATES: Welcome to HBR On Strategy, case studies and conversations with the world’s top business and management experts, hand-selected to help you unlock new ways of doing business.

What does it take to succeed as a business an do well by your employees? Harvard Business School professor emeritus Mike Beer has studied firms who invest in building long-term social value, and he says they do a few things differently.

In this episode, you’ll learn how these companies set their strategies for new products and services, hiring, and even how much debt they take on by first considering their company’s larger identity and higher purpose. Beer calls this strategic identity.

You’ll also learn how they manage the short-term pressures from Wall Street analysts and investors through storytelling that emphasizes long-term results.

This episode originally aired on HBR IdeaCast in October 2011—in the wake of the Great Recession. Market conditions have shifted since it was released, but the insights in this conversation are still relevant.

And just a note, we recorded this by phone. While the audio quality is not great, the conversation is. I think you’ll enjoy it. Here it is.

SARAH GREEN: Welcome to the HBR IdeaCast from Harvard Business Review. I’m Sarah Green. In an economy with high unemployment, the possibility of a double dip recession looming, and debt crises going on over the world, we’re in a pretty tough moment. And it has some people wondering if business can even be a force for good anymore.

I’m talking today with Harvard Business School’s Mike Beer who has some opinions on that. He’s the co-author of the new book Higher Ambition: How Great Leaders Create Economic and Social Value. Mike, thanks so much for coming on the program.

MIKE BEER: Happy to be with you.

SARAH GREEN: So what do you think? Can businesses still do well while doing good, really?

MIKE BEER: Well, absolutely. There’s evidence in many firms, although they’re in the minority, that they are able to run their firms over long periods of time by doing good and doing well. However, it’s important to understand that this is not something a CEO can decide to do in the midst of a depression or a recession, or I should say, the Great Recession, because the things that these firms do are very much long term oriented.

So for example, these firms invest a tremendous amount in building both human and social capital. Which means that they are very careful about hiring, and then they create a culture that motivates people and keeps them attached to the firm and so on. And one of the ways they’re able to maintain the human capital and social capital they build is to prevent doing some bad things in downturns. For example, they generally do not have large amounts of debt.

I’ll give you an example. Southwest Airlines has virtually no debt. They promise their employees they’ll never be laid off in a downturn. They’re able to do that because they have low levels of debt, so they’re not forced into decisions by external stakeholders, shareholders and so on, that they don’t want to make, because they’re too short term.

And they also limit their growth. Their policy for years has been two cities a year, no more, even though they had many opportunities to grow faster. Because growing too fast prevents them from building human capital, that is, hiring people who really fit the firm from a values point of view and have the capabilities required. So their selection ratio is great. They are able to select 1 out of 100 applicants. And secondly, so the limits on the rate of growth allows them to basically get the best people that fit, and also prevent them from overextending themselves, both through debt and too many people that they have to cut back in downturns.

SARAH GREEN: So I want to get in a little bit deeper to this topic. Tell me a little bit more about what they do.

MIKE BEER: Sure. Sure. in. The book, we talk about one of the key disciplines they have is what we called forging a strategic identity. So what does that mean? It means that they, first of all, start the process of deciding what they’re going to do, what services or products they’re going to offer, who they are, what markets they will go into, and what they’re going to do from a business point of view, by first asking themselves, who are we? They start from the inside out, go out, rather than from the outside in.

So what do the worst firms on Wall Street do? They chase profits, profits that were not necessarily in their core area of capabilities or their long term path. They just chase profits. These firms don’t chase profits. They expect profits. They get profits. But they start by saying who are we? What are the capabilities we have? What are people in our organization are passionate about? What do we care about? What are our values? And then now let’s find the intersect between market opportunities and who we are to take advantage.

So again, that also contributes to a somewhat steadier– if you will, slower but steady rate of growth, rather than taking big opportunities, running after them, and finding yourself out on a limb during bad times. So they start by asking themselves who we are and having a view of wanting to leave a legacy. The CEOs in those companies care about building an institution. And by caring about building an institution, that helps them take a longer view.

Now, they also understand, by the way, that if they’re a public company they have to earn quarterly earnings, and a rate of growth in their earnings that’s acceptable to a market. But they manage that tension as best as they can, always understanding they’re building an institution. So part of it is a mindset of how they approach what the purpose of the firm is.

The firms that are not higher ambition firms approach the problem as saying, my job is to satisfy shareholders. That’s where it stops. the firms that we’re talking about, the leaders we’re talking about, have a multi-stakeholder view. They understand that they have to serve the community, the customer, the employee, and the investor.

And by the way, they value investors who are long term investors. That’s another thing they do. So I’ve talked to CEOs who understand clearly that they want to go after investors who have a long view and are going to hold the stock as opposed to buy and sell their stock at the slightest change in value in the market. So it’s the perspective they start with that’s the most important element of how they end up. And then they fashion policies to match that perspective.

SARAH GREEN: I want to talk a little bit more about those short term, stock market driven pressures, because those I know are very real, especially as we’ve seen over the last several weeks now. I mean, the market’s up 100 points one day. It’s down 300 points the next day. You know, it gets really hard to sort of take a long term view, I think, when you have this constant sense of crisis.

And I know that even though you may have the best of intentions towards managing towards long term , a disappointing quarter, just from a stock analyst point of view, even if your company grew, can be really devastating. How do these leaders really push back on that?

MIKE BEER: Well, as I say, it starts, first of all, with the perspective. And what they do is they tell Wall Street the long story, not the short story. Tell the right story to Wall Street, and in most cases that story actually does sell. Most Wall Street analysts understand that long story and are willing to tell that story to the potential investors.

And this is important. I haven’t mentioned it. Another discipline that these companies have is essentially creating a performance-driven culture. When things are tough, figuring out ways to do better in tough times, to be inventive, to be innovative about what they do is by essentially creating high standards and enrolling people in those high standards. Now how do they enroll people in the high standards? They enroll people in high standards by articulating higher purpose.

So using that higher purpose, by people identifying with the company and seeing that it has a higher purpose beyond simply the financial results of the company, they also understand and want to enable the company to be successful in those shorter term financial results. And as a result, they exert extra effort, more innovation, more problem solving to try to do the best they can in those tough times.

So for example, United Stationers is a company not in our book, but we’ve discovered since finishing the book it’s very much a higher ambition company. So first of all, their strategic intent has nothing to do with profit. I mean, they don’t say profit is their first motive. It’s an outcome they seek. Their strategy is to enable their partners to succeed, their suppliers and their customers to succeed. That’s what their strategy is.

And they keep working with those stakeholders, including by the way the community, to try to create a win-win proposition for everyone. And they’ve taken on a higher purpose of serving the community, of doing good in the community. They’ve enrolled their customers and their suppliers. And that gives people a great deal of meaning.

SARAH GREEN: So I want to just get your take on the sort of apparent paradox we have here. Because we have on the one hand these sort of paragon examples of great companies that we all sort of wish we worked for. At the same time, when the rubber meets the road, the majority of companies still seem to pursue these sort of short-sighted strategies. And they really see doing good at odds, I think, with doing well. And they think it’s got to be trade-off, always. How can an idea like this one ever really go mainstream? How do you get more companies to see the value of an idea like higher ambition?

MIKE BEER: It’s a great question to which I don’t have an easy answer. But I do have some answers. First of all, we’re dealing with a very long term proposition of changing the mindset of business, the mindset of business leaders, about what firms are about, what their purpose is. So how do we do that? Well, first of all, to create more linkages between CEOs who are like-minded, and begin to create a movement.

Actually, my colleagues and I at TruePoint are in the process of– have founded a not-for-profit TruePoint Center for Higher Ambition Leadership, whose aim is to create a movement. We’re going to bring CEOs together around this book to begin with, in November at Harvard. We want to put them together in a constructive dialogue. We want them to find other CEOs who are also potentially interested and build a set of norms, a different way of thinking about this that becomes the conventional wisdom as opposed to the unconventional wisdom, which it is now. So one way is to create a movement.

The other way is to begin to use that movement and other forces to try to change elements in the context in which business operates. So i think, for example, we need to rethink some public policy, particularly around the areas of investing and long term and short term investing. We’ve become a speculative society. Investing is out and speculation has been in. And that’s a problem.

So the Aspen Institute, for example, has written papers on this, and has brought CEOs together, and other thought leaders, to begin to think about how various policies with respect to buying and holding stock might be changed to enable more investment, as opposed to short term speculation. So that’s a reform that also has to occur.

Reforms have to exist at the level of boards of directors. Boards of directors, too many of them– the best companies have very good boards. But many boards have a relatively short term focus as well. They focus on their fiduciary responsibilities, the financial results of a firm, but not so much on building a great firm. That’s just not in their vocabulary. They never think about that. They never ask their CEOs about it. They never ask what, in fact, the culture of the company internally is, and getting the truth to speak to power. And that’s required.

And thirdly, and we talk about this in the book as well, is business schools have to reframe leadership, what they’re trying to do. They all say they’re trying to develop leaders, but they never really define what leadership means in the context of building an institution. So the argument I made in a recent blog is that basically what we call in the book integrity is not really what we teach at the schools.

The word integrity means honesty, but the most important honesty is integration. Integration between elements of the firm, finance, marketing, human resource, for example. And integration between who you are and what you’re doing. And that requires an honest, open conversation and transparency about who we really are and how we function.

SARAH GREEN: At the end of the day, though, higher ambition has to be driven by a leader. And a leader is a person. It’s an individual. So what about on the personal level? If you’re one on one with a CEO, and he or she is skeptical about the value of this, what would you say to them about why they should change as an individual and what they would need to change in order to do this?

MIKE BEER: Well, the first thing you do is you talk at the level of performance, OK? The evidence is overwhelming that taking a long view, following some of the policies and practices I’ve described, leads to long term performance gains. It’s just overwhelming. It doesn’t mean, by the way, that you’re always the highest performer every quarter. But on the average, you’re sustained, compounded performance over a long period of time works out to be above average– if not always the highest, above average in your industry.

And so the first thing you want to do is start with that evidence. Now, people’s believability of that evidence is partly related to evidence, but we also know that people don’t always pay attention to evidence, right? so. Part of is related to who the person is. I think a lot of the CEOs we talked about do start with a certain perspective coming from who they are. Whether it’s family, religion, or otherwise, they start with a perspective of wanting to contribute to the larger good.

It doesn’t happen all at once. It happens over a long period of time. I mean, it’s taken us years to build up conventional wisdom. And particularly the last 30 and 40 years, which has been dominated by economists’ theory about agency theory formulated by economists. That has driven us shorter and shorter and shorter and shorter. Well, it took 30 or 40 years to do that. We’re going to have to spend an equal amount of time undoing it and moving to a different plane.

SARAH GREEN: Well, Mike, that is an excellent, excellent point. Thanks again so much for coming on the program today.

MIKE BEER: Happy to do it.

HANNAH BATES: That was Harvard Business School professor emeritus Mike Beer in conversation with Sarah Green on HBR IdeaCast.

We’ll be back next Wednesday with another hand-picked conversation about business strategy from Harvard Business Review. If you found this episode helpful, share it with your friends and colleagues, and follow our show on Apple Podcasts, Spotify, or wherever you get your podcasts. While you’re there, be sure to leave us a review.

And when you’re ready for more podcasts, articles, case studies, books, and videos with the world’s top business and management experts, find it all at HBR.org.

This episode was produced by Anne Saini and me, Hannah Bates. Ian Fox is our editor. Special thanks to Maureen Hoch, Ramsey Khabbaz, Nicole Smith, Erica Truxler, Anne Bartholomew, and you—our listener.

See you next week.

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