Episode 151: The Joshua Principle: Empowering Change in Healthcare

Mike O'Neill: Welcome back to Get Unstuck and OnTarget. I'm Mike O'Neill with Bench Builders. Whether we're working with supervisors to improve their people skills or it's me coaching a CEO one on one, getting leaders and companies unstuck is at the heart of everything we do. And that's exactly what this podcast is all about.

Joining me is Echo Vanderwal. Along with her husband, Echo is the co founder of the Luke Commission. In 2005, following Harry's graduation from medical school and Echo's graduation as a physician assistant, the couple and their family moved to the kingdom of Eswatini, Africa, to serve the most isolated and underserved populations.

Seeing the devastation of HIV and the AIDS pandemic, the Vanderwal's quickly realized the magnitude of the need for compassionate health care in Eswatini. Working with a local team of eight people, the Vanderwal's launched the Luke Commission, developing a comprehensive healthcare platform to integrate essential health services with HIV testing, prevention, and treatment.

Today, the Luke Commission has grown to a staff of 700 hosting over 280, 000 patient visits annually at their fixed site called the Miracle Campus Hospital and over 1700 outreaches across Eswatini every year. Goodness gracious, we've got a lot to talk about. Welcome Echo.

Echo Vanderwal: Thank you very much. Thanks a lot.

Mike for having me.

Mike O'Neill: Echo, I was interested in inviting you as a guest for several reasons. So let me see if I can kind of set the stage. Uh, 1 is the fact that you and your husband felt a sense of call to go do something. And at least in my view, what y'all chose to do would take. Me and my wife very much out of my comfort zone.

But y'all not only moved, you move there with your family and you have added to that family and you have grown a phenomenal organization. And therefore, I would love to learn a little bit more about your all story, particularly about the Luke Commission. And what caught my attention when we were talking prior to scheduling this podcast is that you have built an organization and you've built it with the mindset that yes, y'all are co founders, but you're building it with the idea of empowering others.

And you referred to that as the Joshua. Principle, and I would love to learn more about what that is and how that works, because I think that will be of interest, uh, to leaders listening to this podcast. So that's a mouthful, but as a starting point, the Luke commission, um, I'm assuming that, uh, it as a name comes, it's a biblical reference, but can you kind of tell us a little more about why you named what you're doing as the Luke commission, please.

Echo Vanderwal: Sure. Thank you very much. We named it the Luke Commission after the Bible doctor Luke and after the Great Commission, and particularly after the TLC, tender, loving care, because we feel felt like that was our calling to address the marginalized and the vulnerable who are struggling to access quality health care and what in our experience, the most important thing is love and compassion.

Mike O'Neill: When you moved to Eswatini, um, my sense is that, that, that was in the kind of the height of the, uh, we're in, I'm in the United States and therefore, uh, trends might be on a different timeline, but my understanding is that where y'all are serving, um, there is a, a relatively high, uh, concentration of, uh, uh, HIV.

Um, am I remembering that correctly?

Echo Vanderwal: Yes, you are. Actually, my husband and I came to Eswatini for the first time in 2004, when Harry was finishing his residency, and Eswatini actually has the highest HIV prevalence rate in the world. And when we came to Eswatini for the first time, it was really at the height of the HIV pandemic.

And someone took us, picked us up from the airport, and took us to a rural area. And when we got there, we found people in their houses everywhere that were dying. young people in their 20s and 30s. And when we asked them why they weren't going for health care, they said two things. One, they struggled to get money for transport.

So transport seemed to be one of the biggest barriers to people accessing health care. And the second thing, um, was that people felt stigmatized and our culture is very shy and quiet. So you can easily. Marginalize someone. Um, and we recognized then that compassion had to be the cornerstone of any work that we did here because when you're working with something that's very stigmatized like HIV, it was very important that people feel loved first and foremost.

And with that platform set, it's much easier to work on those more difficult to treat diseases. But we did walk into really the epicenter of HIV at the height of the HIV crisis. In and we felt called, uh, we had. Had a calling when I was 8 and my husband was 17. We met when we were 19 to work overseas in Africa.

We didn't know where we didn't know what it would look like. And then, as I mentioned, when he was finishing his residency, we were able to come to and when we saw people in their houses dying and the children who were left behind, we really felt that we were supposed to go to the people, not ask them to come to us or to a fixed facility.

Initially for the 1st, 8 years. We. Ran what they call the mobile hospital in rural parts of Eswatini and our main goal was to we felt that we were supposed to delay orphanhood by making sure that parents were on treatment and so making sure that parents were getting the treatment they needed allowed them to live and raise their own children and obviously we all know you know that our goal is that parents are raising their kids not Orange.

Kids being raised in other environments, um, after their parents pass away. So those, those, that was our focus for the first eight years. And, um, it's grown since then, but those were very important years for us to understand what are the limitations? What are the barriers? Why do people struggle to access care and really to walk in their shoes by working in the rural areas?

We were able to walk in their shoes.

Mike O'Neill: The perspective that I will probably be asking my questions is from that of, A leader, a leader who identifies the need and begin to kind of. Address what can be done about that need. It could be in a business setting. It can be in a setting like you're describing, but you saw a profound need and what I understand is y'all concluded pretty early on.

There's no way you can even begin to address that need until you have built trust, built rapport, and you put such emphasis on compassion. The Luke Commission abbreviated TLC obviously kind of reinforces that. Start. Met that you were doing what you were doing for the 1st, 8 years before you built. Um, what I understand to be kind of, is it, are you referring to it as the miracle campus hospital or just miracle campus?

Echo Vanderwal: The miracle campus hospital yes.

Mike O'Neill: Now, is it still more in a rural setting?

Echo Vanderwal: It is, but just by nature of where we're able to buy land, uh, there's only 20 percent of our land that you actually buy with a title deed. And so the location of that land is a bit limited, but we are very blessed to be on a main artery, a big road, um, and are able to access, we're right in the center of the country, and we're able to access all 4 regions of the country very easily from this, three to four acres of land.

Central location, but, um, what, what actually happened is that, uh, as we were working in the rural areas, we continue to identify needs and we would work to meet those needs. We recognize that if we push logistics or challenges back to vulnerable patients, typically, that would just mean that they would not be able to continue their treatment.

And so it's very important for us to be a solutions focused organization. And to bridge the gap and make sure that we bring a complete service to the people. And so we had committed, we, we, we say there's a tagline on a lot of our documents and that we talk about every last one. We always stay until every person's taken care of.

Even today we take care of about a thousand people a day with a team of 700 and they stay until every person's taken care of. And, um, In the process of doing that, when we were in the rural areas, we found people that had TB and they needed to be admitted to a TB hospital. They were sick enough to be admitted to hospitals, but when we would call to get ICU beds or TB beds, um, they wouldn't be available.

And so we decided to build a fixed site. Hospital at the Miracle Campus so that from all of these outreach locations, as you mentioned, we go to hundreds of outreach locations every month. And from those outreach locations are able to refer back to the Miracle Campus Hospital as a referral center of excellence for the teams that are moving around the country.

Trying to be as close to the people as possible, but yeah, I can talk a little bit about the process of growing from 8 to 700. It was, it was definitely over time. You start to realize that, uh, there's more people that need serve than you can serve with yourself and a small team. But I do believe those early years, the pioneer years of learning what the challenges were in the barriers were very important then to moving to a scaling.

Uh, scaling period in, in the organization's history. And so, um, the other thing that we also recognized is that medical care is 24 hour a day, 7 day a week, 365 day a year job. So how do you make sure that people are refreshed and that they rest, um, and don't feel overwhelmed or overworked, especially in a low resource setting.

It's very important to, to, to plan and coordinate, um, for those things. And that's where the Joshua principle came in, because as we started growing the team and you would raise up leaders. Local capacity building has been so critical for us, uh, and so important because even though I've been here for 18 years, I will never be able to connect at the same level as someone who was born and raised in Eswatini, and so they connect on a different level to the people that we serve than we do.

Obviously we work together as a harmonized and coordinated team. But the role that the national team plays is really, really critical. We also recognized. That in the culture, there was, um, quite a, quite a bit of concern. If you train somebody for your job, it means that you won't be needed anymore. And so we had to overcome some of those cultural beliefs that I might work myself out of a job.

Obviously, scaling from 8 staff to 700 staff, it was a little bit difficult to work yourself out of a job because things were always growing. Um, and over time, the team started to recognize how important it was for all of us to train our Joshua. And so that has just become part of our organizational tapestry, um, where everybody is always responsible for training someone to be doing what they're doing.

And then that gave the ease of movement, um, for those leaders to be able to move into other positions when they opened up, or when there needed to be, uh, organizational shift or pivot, it was very easy to move, um, staff around. So it's been a real joy to be able to watch the team now celebrate each other's.

Progression and growth, instead of looking at other people growing as something that might be bad for me looking at other people growing as meaning that I was successful in my leadership role. And so I really believe that this. Allowed us then to scale what we said at the beginning was most important, which was compassion because we needed to scale compassion to be able to serve so many people in 1 day.

But how do you scale compassion? You don't have the leaders to do that. And so the Joshua principle really was the catalyst for us to be able to raise up a team of 700 and it wasn't us that raised a team up. They raised each other up over time. It just started taking on, um, you know, kind of a motion of its own and it's just been really, really exciting to watch and.

You know, when people come in a very African context that comes to the hospital, they say, it seems that you are all born from the same mother. And that just really means that we're all operating with the same heart. And I think that that is a real testimony, um, to what the Joshua principle has done over the, over the past decade to grow up what is now a team that's taking care of a 3rd of our nation's health care in Eswatini.

Mike O'Neill: My goodness. Uh, therein lies what really drew me to wanting to have this conversation. Um, and that is. Uh, you refer to the Joshua principle, but for those who are not familiar with the biblical character, Joshua, can you explain Joshua and why you adopted Joshua as a name and to embrace this concept?

Echo Vanderwal: Sure.

Another, another way that we also describe it as twinning. Um, and in order to cover 365 days a year, 7 days a week. 24 hours a day, it's very important that we have twins or triplets, um, but they were always replicating ourselves. And, um, when, when Moses was working with Joshua, who was, he was learning and, and, and copying and doing, it extends the reach.

It extends the, the ability to serve more people in our context. Um, and so that's where, that's where we saw that principle being important. I don't have a job to secure a position for myself. I have a job. Because this leads to a bigger cause, a bigger outcome, a bigger result when I'm working in harmony with a group of people.

And that means that if we have gaps, especially in an operation that runs 24 hours a day, it's very difficult. And it causes a lot of operational glitches if we don't have. Consistent coverage all the time. Um, and, and that this twinning process has really helped us to be able to scale in what I would call a healthy manner.

I'm not in a way that would be detrimental to either the staff or to lower the quality of care for the patients.

Mike O'Neill: You know, in my work as a consultant, I oftentimes work with organizations that are growing and they struggle with are what I might would commonly refer to as growing pains growth. And Is good.

Um, if you're growing, you're helping more people in your setting. If you're growing in a private secting, um, you're generating more revenue, you're able to deploy more in the light, but with growth comes a whole new set of problems. Um, what caught my attention with what you just said is scaling is 1 thing.

So let's 1st start there. And then I want to come back to this notion of scaling compassion. You saw a profound need. You started, um, with a small staff, it continued to grow. Did you find that y'all had to kind of put the brakes on growth at times? Or did it, that pace of growth kind of mirror y'all's internal capacity to take care of it?

Echo Vanderwal: Can I be honest?

Mike O'Neill: Please!

Echo Vanderwal: I've always felt like the trains running about 20 percent faster than it should. And I've tried to at times, you know, in my position to pull the brakes. Um, because we also are faith driven. We understand that sometimes as you mentioned, um, you know, moving here might have been uncomfortable for you and your wife.

And there's also discomfort for us. It wasn't moving to another country, but there's discomfort at times. With the amount of work that needs to be done in the resources that you have. Um, and so I wouldn't say we have at times slowed down the growth or said there are certain areas that we are going to not work in because we want to prioritize other areas or boundary lines that we've said we're not going to cross because it's just not an area that we're prepared to to work in right now.

Um, but. Most of our decisions have been based on needs on the ground. Uh, and so you start to assess that and analyze that and start to build a coordinated plan to address it. And at times, those plans move at different speeds. Um, we, I can give you an example. We've been working for a long time. There's no one doing hip replacements in our country.

So we have people that have broken hips that are lying in beds and obviously have a lot of, um, other challenges because of their inability to move. And so we've been working for a long time on establishing, I would say about three or four years, we've wanted to establish a consistent and reliable hip replacement program at the Miracle Campus.

And we've finally done that. It probably didn't go exactly at the speed we wanted. It was a little bit slower than what we would have wanted, but we feel that we have set a foundation now for something that can repeat itself, um, and, and, and is not a flash in the pan. So sometimes it's slowing down to establish something that is more consistent and reliable for the long term rather than doing something fast that of course burns out quickly.

So. There's a lot of moving parts, um, because health is so multifaceted and we don't have the opportunity really to refer people for specialty care. So we use a lot of, we do a lot of creative and innovative things. Like, we consult with about 100 different specialists around the world remotely on our digital platforms.

And that allows us to bring specialty care to a Fairly small country of 1. 3M people that would not be possible to bring to this country. Um, if you are waiting for a human to come here, but you can definitely use technology to reach across the ocean. So I would say sometimes slowing down the growth may just mean using a different tactic, um, i.

e. technology or digital systems that would have taken something that would have been a lot harder to do without s Um, that innovation and inserting the innovation in order to decrease the workload. So it is, uh, as is in any industry or any sector, um, very much like a puzzle pieces that you keep moving around to try to make a complete picture.

You know, we could spend our entire time just talking about the mechanics of growth, but when you made reference to scaling compassion, I likened that to organizations that start small, early, uh, employees, those with the most seniority. They had this sense of who we are, and we're like family, and I know that, at least in my work, as organizations grow, those particularly long term employees begin to feel it's just not the same.

Um, we've lost that sense of family feel. That's a challenge, but then there's the also this notion of scaling compassion, and, um, can you elaborate a little bit on that? Did you find and have y'all found that that's one of the things that you have to kind of be intentional about? Staying true to your core and to the the primary purpose that you founded this mission.

Yes, definitely scaling compassion initially was probably the hardest thing that we've ever done. And you might think something technical in the medical field or working in a resource limited environment or working in the highest HIV prevalence rate country in the in the world would be the biggest challenge, but actually Recognizing how critical calling was and that calling tied to compassion, because when you're called to something, it's much easier to be passionate or compassionate in in that setting.

And we were told many times by people that I really respected that it is impossible to, to instill or put a calling in someone that calling comes. From God, or from, you know, something that's happened in that individual person's life and what was very interesting for us is that I would think at one stage, probably 12 years ago.

I've I've maybe even believed that it was going to be difficult to scale compassion. I will not say we have difficult years or difficult periods, but starting to decode what drives our culture, what is missing in our culture, where there are things that need to be repaired or restored in the culture was very important.

And I would say that a very pivotal time for us is when we recognize about 7 or 8 years ago that we were employing the adult orphans of the worst of the HIV crisis. And when you really started listening to their stories, when they were free enough to share, because that's a very difficult thing for someone who hasn't grown up in a safe environment to actually share how they feel.

When we started hearing their hearts, we started recognizing that there wasn't a sense of belonging. And yeah, now you go back to this part about family. It doesn't matter who we are. We want to belong somewhere and we want to be accepted no matter what, somewhere, and we want unconditional love and where do you get that if you've lost your nuclear family due to disease or, or other reasons, and we started to realize if we did not back up and work on this, what I would call inner healing process that we were never going to be able to scale compassion.

You can't ask a person, um, Who is wounded to heal. We heal when we're healed. We wound when we're wounded. And so we really recognize that this needed to be very intentional. This is probably the most and you would, you might not believe this because it's a very technical space that we work in, but actually the induction process and the inner healing process.

And the valuing of the human staff member who's coming into the organization is now probably the most intentional thing we do. We literally do not take one person in the organization who does not go through 10 weeks of induction. And this induction process is multifaceted around leadership development, around personal development.

Um, around over time, as we get deeper into the 10 week process, then we open up times to start talking about how did you grow up? Who did you grow up with? And and and to unpack those things that have impacted them and actually play a major role in how they respond to other people because what we were finding is if we didn't have this intentional process, if we send people directly to the hospital, they would actually not treat the patients.

Well, and it's because. There was not a full understanding of what it looked like to be compassionate or to receive compassion or to give compassion. And so this has been a very intentional process for us. We've graduated about 1, 300 people from our induction program, which we call base camp. And I would say that this is the most transformational thing we've ever done.

It's more than taking care of 300, 000 patients a year. It's more than seeing people really go sometimes from deathbeds to, to, uh, very productive life. Seeing people's hearts healed and what happens then and how they can heal other people has really been the most thrilling thing that we've done in our 18 years here.

And what I've loved so much is when people's hearts are healed and they feel accepted. They feel like they belong. They feel like they're safe. They feel like they can make mistakes and we will just work through them together. Um, they start to be that same way with other staff members. So. Even as we've grown, they will still call this place a family, or they will still, you will still sense that intimacy, um, because if, what we've found is if we can train that at the lowest management level, we have 10 management levels in our organization, and that's before you get to supervisors and team leaders.

So there's like 10 management levels. If we train that to the, Thank you. M1 management level, all the way from down from M10. It is deeply embedded in the organization. So it's just not acceptable for management or for leaders to, to mistreat staff. Like, we, those are just some non negotiables in our organization.

And it then creates a safe. Place for people to learn and grow. And, um, and we've just found that that has been able to help us to retain the family space, which for us in our setting is critical because of that loss of that safety of the family space during the worst of the HIV crisis.

Mike O'Neill: I find this fascinating for so many different reasons.

Um, in my work with organizations, um, we probably would put a label on that and that's culture and that's what is our culture. How do we foster that culture? And what I'm really intrigued by is the recognition, um, on y'all's part of the criticality of, um, addressing these very, very fundamental needs.

First, Before they can even be of help to others, um, I would love to kind of come back to something regarding self care and that is, I think I heard you correctly, but if you, if I heard you right, your organization is serving roughly a third of the population of the kingdom. Is that right? Yes. Wow. With that much need, with that much delivery of quality healthcare, quality, compassion, and the like, in what ways have you been able to kind of work self care into the fabric of being part of the, the TLC family and being an employee?

Echo Vanderwal: Thanks for that question. And it was definitely an area where. Probably myself more than my husband, but definitely I had to grow in because I'm, I'm a person that is very goal driven. I, I can work really hard and it's okay. I enjoy it. Um, but I would say for the 1st, many years, we're very focused. I mean, people are dying around you everywhere.

It's hard to think about the fact that you don't have a comfort that you want when you see parents, um, Dying and leaving their kids behind notice a very much a war like type of atmosphere that we started in here. But what I'm very grateful for is that we have a local board in and

African culture, our culture, your staff can never do more than what you're doing. So if you set. The bar very low in the area of self care or even just, for instance, building a home for yourself or taking care of yourself, your staff will never be able to do more than what you're doing. And, and I would say, because now I'm motivated, I don't want to hold anybody else back.

Um, then you start to push forward and take better care of yourself. And then that, that gives space, um, for you actually to take care of the staff in a better way and to train self care, um, to your management team. And leadership team. And because of the absence of some of the nuclear families, we end up having to care for each other, um, in ways around funerals.

You know, you will have instances where people will lose someone in their family. They don't have anyone to go to the funeral with. So, you know, you start to create this space internally where we take care of each other, which allows space for self care. And also you, you, you are Burying each other's burdens, um, in, in a way that just makes the load lighter.

It is a very special space here. I really didn't think I would ever work in an environment like this. We have had a lot of challenges, a lot of very difficult things right now, to be very honest with you, the nation's healthcare system is severely broken. It's the worst we've seen in 18 years. Um, we are the national, the, the, the, the central medical stores is out of medications out of laboratory supplies.

I didn't want to go deep into it. It's on the front page of almost every newspaper. It's been a very difficult period, but inside of this institution, this team is unified. You talked a bit about. Being intentional about the culture and that is something that we do every single morning. We meet in small groups in our departments.

There's 45 departments. We all meet in small groups in our departments. We go through our core values. We go through our creed and those are things that we talk through and recite every day so that we remain grounded and connected to what brought us here in the 1st place or what the motivation was for this meeting.

Organization to even start. Um, and I will tell you that I just see this happen naturally once the staff feels like. I'm safe to take care of each other. I'm safe to take care of myself. I can easily self declare, you know, I'm not doing very well today. I think I need a few hours off. I think I need to, you know, we do that all the time and for each other.

I just saw someone behind a building crying. I just saw, and we have a dedicated, Mike, we have a dedicated staff. Care team that immediately those reports come in. Someone will move to that staff member to support them. And I really do not think we could cope without that. Staff development team because they are the ones they're like the glue that hold the team together and bridge all of those challenges that we face every day.

And that's their dedicated job. They don't do anything else. That's what they do. And so those are some of the keys that we figured out over time. Um, as I mentioned at the beginning, I used to run really fast, really hard at goals and have really recognize that the health of the team is the most important.

And critical. Component to making sure that we accomplish those things that we're here to do. And if we do it, while we are not taking care of the team, we haven't done our job. Well, and and so I, I do think that. Over time, it's been built into where a bit of a military type of operation, very coordinated, very planned.

Um, you know, we're very component based. We know these components need to be together to, to, to make a complete picture and we've just recognized that the staff development team, the staff care team, they have to be as important in our organization as the doctors, as the nurses, as the laboratory, you know, it is a key component to us doing well over the long term.

Mike O'Neill: I anticipated that I'd be hearing parallels that could be applicable to anybody listening. And I have done just that, you know, echo as you kind of reflect on our conversation today. And if you step back and say, of all the rich things that you've shared with us, what do you want to be those takeaways?

Echo Vanderwal: Well, thank you for the conversation. Really appreciate it. And I think the takeaways for me are things that we think are going to be the hardest. Become the most natural over time. I would say that about scaling compassion that seemed like a mountain. We couldn't climb, but because we didn't give up and we were determined to be able to take care of more people.

The other way to do that was to scale the most critical component. Um, just, I think that the, that the key is resilience during those times when you feel like there's something you can accomplish to not give up on those goals. Um, and. And the scaling of compassion has probably been the thing that has been most beautiful to watch, because it is wonderful that it doesn't require my husband or I to take care of a thousand people in a day anymore.

That happens without us. And I believe, I didn't really talk about this, but getting to the place as a leader where you can obsolete yourself from the equation and have the same outcome is The most, um, fulfilling thing, I think that can happen, uh, in our journey as a leader.

Mike O'Neill: I hate to open the conversation back up, but what that does for me, it kind of points out particularly, um, business founders.

Uh, their, their identity is so wrapped up in the organization they have started, and if you don't do the things that you've shared with us, it is very, very hard to let go, but what I'm hearing you say is that the intentionality of twinning, not only yourself, but replicating that throughout the entire organization, and the intentionality of making sure that we do not lose sight of who we are and what we're all about, What I love is the emphasis on we've got to take care of our own first.

We're going to be able to have a, an impact outside. And, um, I'm sitting here and just, I'm just soaking this all in. I know that folks who are watching or listening to this, um, are probably been drawn in like me. If folks want to reach out to you or to your organizations, what's the best way for them to do so.

Echo Vanderwal: Thank you for that. If you would like to reach out to us, you can reach out to us at www.lukecommission.org, luke commission.org, or you could info I N F O @lukecommission .Org.

Mike O'Neill: Excellent. We also have some other links that will include in the show notes for those folks who want to learn more about, uh, the loop commission, um, and or be able to reach out to y'all directly echo.

Thank you.

Thank you. Thank you very much. Really appreciate the time. Thank you. I also want to thank our listeners for joining us today for even more insights about getting unstuck and moving your business forward, I invite you to subscribe to the Bottom Line Newsletter. And you can do that by going to our website, bench-builders.com. So people have begun asking, you know, Mike, I know you're a podcast host, but tell me, what do you do? And I'm finding myself trying to answer that succinctly. So let me make a stab at that. I found that the clients that we work with, they usually had one. Two problems. Either they were frustrated because they were losing the employees that they wanted to keep.

Or the leaders, they found themselves stuck. They were stuck in the weeds of the day to day, and they're failing to execute on their long term strategy. So if you're listening and you're experiencing high turnover or poor execution, and that's slowing your growth, let's talk, head over to bench-builders.com to schedule a call. So I want to thank you for joining us. And I hope you have picked up on some quick wins from Echo that will help you get unstuck and on target.