Entrepreneurial Leadership Within An Established Business


Dylan Steer, MD, is a kidney specialist (nephrologist) at Balboa Nephrology Medical Group (BNMG) and Executive VP transitioning into CEO for BNMG, a $40 million company with 16 clinics, employing 130 people.  He grew up in Boston then moved away to college in Ohio and continued onto medical school at Duke University studying internal medicine, where he also completed residency.  After receiving further training in San Diego for kidney diseases and nephrology, Dr. Steer accomplished a fair amount of research at UCSD, in the development of artificial kidneys.  Although it was rewarding, he enjoyed caring for patients more than lab animals so he moved on from research to practice in 2003.  Dylan is not only a successful medical physician but also an accomplished entrepreneur in his field.


1) Getting your established board to think entrepreneurially

  • What tips and stories can you share about getting your board to think entrepreneurially?

“The entrepreneurial state is really a temporary state; what we’re looking for is a way to develop a scalable and repeatable business life.  When I try to get my board to think entrepreneurially, the first thing I do is attempt to sell them on a vision and have them think of the future state and what’s to come.  That helps frame the discussion for any operational elements of how one gets to that state.  As we develop the business, we’re looking for elements of our operation that propel us forward; I can refer back to that vision of the future state and test the operational elements against that vision.”

  • How does this play a factor in the long term growth of your business?

“As CEO, the challenges I have are not based on developing new business; first is maintaining recurring business.  The long term viability of the company is really based on maintaining current business, developing new business lines and growing.  For my particular board, I could easily focus them on our current business but it’s more of a challenge to focusing them on future growth.”

  • What resistance have you seen around this topic and how have you overcome it?

“The entrepreneurial question is really about the future state.  What if we get something new?  What if we approached this problem in a particular manner?  What if we looked at the problem from a different angle?  That’s the entrepreneurial way to think about business and having our board engage in that discussion is one of the areas I have difficulty with, which is why I focus on lighting that “what if” question.  Once you engage in that discussion, it’s very easy to start the entrepreneurial process.”

  • Do you have any examples of resistance you have been faced with and how you overcame it?

“One of the key things in developing an entrepreneurial spirit within an established business is creating a protected area within the company so it can happen.  The maintenance is outside of that space but the innovation of a different sector within the business, where one is allowed to fail without repercussion, is key.  The resistance that I’ve seen when I’ve created a new program, is usually around trying to judge them around established metrics and those metrics are always, what is the return on the investment?  In the entrepreneurial world that’s not the first question one should ask.  The way I have overcome is that I’ve created an innovation sector; a space within my own business where risk taking is encouraged and where failure only leads to a better iteration of the product.”

  • How do you believe thinking entrepreneurially changes the decision making process of the board for positive? Anything negative?

“Entrepreneurial thinking in a board can help the individuals focus on growth through the future state and has them thinking forward rather than about the present.  It could be a double edge sword, however, because you can’t take your eye off the ball either.  A futurist once told me, ‘the future determines the present’ and I really believe that.  The way I think about the future determines my present action and working with a board to have them think about the future will help us determine our present.”

  • What is the fear of an established board to think entrepreneurially?

“No one likes to make mistakes; the fear of a board is getting it wrong.  I’ve overcome it by creating a space where it is okay to make mistakes.”


2) Creating Long Term strategies is Key when everyone is focused on the short term tasks

  • How do long term strategies conflict sometimes with short term goals or tasks within your organization? How do you balance?

“The role of the CEO is to really look at the long term strategy and mission of the company; I focus my COO on a lot of the day to day tasks.  I will say, however, that those day to day tasks should fit within a framework that supports the long term strategy.”

  • Why is it crucial to be focused on long term strategies alongside short term goals?

“Your business exists in real time; it exists in the day to day and in the short term, that’s the tempo of a business.  The direction of the business, however, is headed towards the long term strategy; therefore, if you’re not focused on long term vision and you’re only focused on what’s going on in the moment, you’re directionless.  Conversely, if you’re only focused on the long term vision and not day to day management, your head is in the clouds and you’ll never get there.”

  • In what ways have you used profit and the bottom line to incentivize long term behavior, especially when profit usually comes in the short term?

“In our medical group, our physicians are incentivized to work hard; we have a hybrid model of productivity and quality.  Their compensation is based on their productivity; in other words, how hard they’re working, with some modifier for the quality of care they deliver.  It is not just about working hard but also delivering excellent health care.”

  • How does your entrepreneurial background play a factor in the decision making process when looking at something long term versus short term?

“My entrepreneurial background allows me to be comfortable with uncertainty, risk and asking the “what if” question; I don’t always know the answers but I really love asking the questions.”


3) Implementing performance based metrics and accountability amongst a group of peers

  • In what ways have you created metrics and accountability amongst your colleagues?

“We have a number of quality dashboards that we publish internally for everyone to see, which brings out the competitive spirit in all of us.  Doctors are very competitive; that’s how we got into, and excelled in, medical school; it’s in our DNA.  By publishing these dashboards to our physicians, I harness that competitive spirit, especially for the physicians that may have had a drop in their quality.  Furthermore, I let the doctors who are at the top of the quality leader board know that they’re only as good as their last patient, meaning, one shouldn’t rest on their laurels; you can’t be complacent and feel as though history will propel you forward.  The physicians in our group must go through a continuous quality improvement process in order to excel.”

  • What resistance did you have and how did you overcome it?

“Nobody likes to be on the bottom; the problem with performance based metrics is there are always disagreements on what quality is and the best way to measure performance.  When the facts are against you, you argue the law and when the law is against you argue the facts; when someone is at the bottom of the performance pile, they argue the law, in other words, that the metrics weren’t there.  On the other hand, it’s okay to have imperfect metrics but you have to start somewhere and you have to measure to improve.”

  • Why do you think that resistance exists?

“People at the physician level believe that they deliver excellent care, many of them do, but not everybody.  It’s a challenge to want the ego to see that, when measured objectively, their performance is not on par with the care their peers deliver.”

  • What are the benefits and disadvantages to having these metrics and accountability?

“Without metrics, you have no ability to decide on how to improve your program.  One disadvantage is in the presentation of the metrics; it can turn people off if it’s presented as a judgment.  Therefore, when we talk about our metrics, we just present them as fact.”


4) Wearing multiple hats and creating strategic relationships

  • You mentioned that you are very involved in different positions, why is wearing multiple hats a key part of your success?

“On a personal level, I love it.  I love to be involved in multiple levels within my organization.  It keeps me tied into what’s happening on the front lines and in the trenches, allowing me to bring back to the board room what I see happening on a day to day basis.  Secondly, by having multiple interactions on various levels within my organization, it really lets me lead with the mantel of authenticity.”

  • How does creating strategic partnerships and focusing that, help all of your positions?

“No one can be CEO alone; it is not a one man army position.  I spend a lot of my time leveraging my relationships using “emotional intelligence” and harnessing the talents of my employees to improve our company; I might set some of the direction but I spend most of my time listening.”