Operating Principles, Culture, and the Nexer Experience

Introduction

Our mission at NexHealth is to accelerate innovation in healthcare. We do this by connecting patients, doctors, and developers.

In the long run, the way to look at our product is that we’re a protocol moving data from point A to point B. Today, we help The Smilist (dental office) send data from their servers to TrueLark’s servers (a software company). In the future, we want to be able to send data from a hospital in the US to a Roche lab in Germany. We simplify the movement of data from point A to point B.

However, we know the entities that hold the data, EHR vendors, insurance carriers, pharmacy chains etc. do not want this data to be so easily interoperable. On the other hand, people that actually need to use the data for treatment or other operations, like doctors and patients, want to use our technology to move their data from point A to B.

This, by default, means we’re taking on the whole “system” at a global scale. Sometimes it will be adversarial, but our hope is that most of the time it will be friendly through established and formal partnerships. Executing on this roadmap means lots of high quality decisions will need to be made, challenges overcome, all while growing revenue and the customer base.

Making the right decisions, solving challenges, and growth are only possible through the right culture. A culture that’s built specifically for NexHealth, our market, and context. Everything defined in this document from the Operating Principles to how we hire and hold 1:1s is designed to help us build that specific culture for NexHealth.

Starting with our Operating Principles. Our Principles are designed to help us make decisions that solve both our long term and short term challenges.

Our long term challenges are: 
  • Doctors are focused on providing care, and are less tech savvy as a result.
  • Historically, healthtech has not been an attractive place to work for ambitious talent. 
  • “The system,” - EHR vendors, insurance carriers, pharmacy chains, and any entity that holds consumer data - is resistant to change.
Our short term challenges:
  • Keeping customers insanely happy.
  • Growing our customer and revenue base quickly, month by month.
  • Expanding our TAM.
  • Building a great team.

Executing with urgency is how we are going to accelerate innovation in healthcare. In the last 24 months, we went from 5 people to 180 people, $4M in funding to $176M in funding, and $18M valuation to $1B. We are keeping a similar pace of doubling year over year and are delivering value to customers across the healthcare ecosystem.

Operating Principles

To achieve our lofty goals and propel our growth forward, each of our actions and decisions stem from seven core operating principles: 

  • Solve the customer’s problems, not yours
    When making decisions, think from the perspective of the customer. It’s easy to make decisions that make our lives simpler, but not the customer's.
  • Do the things others are not willing to do
    As a Nexer, always go after the hardest problems. Pursue things at the highest quality. Move at the fastest pace. 
  • Take ownership
    Act like a founder. Own your roles, destinies, mistakes, behavior, and our mission. The buck stops with each of us - no blaming or excuses.
  • Say what’s on your mind, with positive intent
    Be direct, proactive, transparent, and frequent in your communication. 
  • Default trust
    As a Nexer, you do not have to earn trust, trust is given to you by default. If we by default trust each other, our speed of communication, feedback, information sharing, and overall improvements will be a lot faster.
  • Think in first principles
    We first identify the problem and then break it down to its fundamentals before diving into solutions. We constantly ask “why” to validate our assumptions. 
  • Live in the details
    As a Nexer, you should know all the details about all the things you do. If you’re in the details, you will make high quality decisions.

Building a Lasting Culture

Why do some cultures last thousands of years? Why do some die off while others persist generations after generations?

It’s because of the daily rituals, beliefs, and lore that the culture lives and passes on from one person to another. For example, meditate every single day, attend church every Sunday, wear your team’s sports jersey on game day, believe in a specific creation process, respect cultural artifacts, etc. 

A group of people sharing common daily rituals, beliefs, and lore means those groups of people feel strong kinship, trust, and passion. And they enthusiastically pass it on to the next group of people. Similarly, in order for NexHealth to build a lasting culture, we need to have our own set of common rituals, beliefs, and lore: our own way of operating.


In addition to our operating principles , here’s our way of working:
  • Non-hierarchical
    We’re not a traditional hierarchical company with hierarchical titles and all the politics that come with it. We’re a culture where people’s impacts are measured in scope and outcomes, not their titles. As a result, we've replaced titles with job scopes, and have internal levels and ladders so we can properly reward Nexers as they progress in their careers. 
  • Talking to customers
    Every Nexer uses our product and visits a real customer in their first two weeks. 
  • Document culture
    Most decisions are made over written, narrated documents, and not meetings. All documents, recordings, meeting notes, emails, Slack messages etc., should be easily searchable by everyone across the company.
  • Communication etiquette
    Email
    Email should be used for most communication, especially when the recipient needs to either take an action or give a thoughtful response. Each team should have an email distribution group where all emails get CC’d to. For example, if a marketing team member is sending an email about an event, the marketing team alias should get cc’d. This way the whole team has access to all emails that they can search for and read on their own time.

    Slack
    Slack should only be used for quick, urgent, and non-thoughtful communication.

    Meetings
    Having a meeting should be the exception, not the default. We try to avoid holding meetings. Instead, we write documents and circulate to as many people as possible for alignment, comments, and visibility. Only hold meetings if there is no alignment after circulating your written document. If we do need to hold a meeting, ensure that each meeting calendar invite is populated with a well written document articulating your thoughts, questions, and action items in advance of sending to your peers. Include as few people as possible in meeting invites.
  • Metrics visibility
    Every Nexer, regardless of their role, has visibility into all of our core metrics in real time. You can’t take ownership if you don’t have the right information.
  • Celebrations
    There should be company wide celebrations like offsites etc., but each team celebrates their own team and performance through symbolically important artifacts (like Allbird shoes). 
  • Rituals
    It’s important for Nexers to participate in all of our company-wide rituals like the weekly all-hands, visiting customers, offsites, planning sessions, Allbirds, etc. 

Beliefs

Our company was built upon certain beliefs about the market, the world, and how we want to shape it. These are a few important ones we share: 

  1. Incumbents are entrenched in a business model that does not want data interoperability, but healthcare data should be freely interoperable.
  2. Free exchange of data will enable more innovation. Through faster innovation, most problems in healthcare can be solved.
  3. The government can’t build the solution.
  4. We are a tech company and not a healthcare company.
  5. In the next decade, there will be an Amazon or Microsoft of healthcare. NexHealth will be it.
  6. NexHealth is supposed to be hard. We’re not riding a market trend to success, we’re creating our own success by manually rewiring healthcare data flow. Similar to Amazon rewiring the physical world with warehouses and shipping logistics to succeed vs Google riding the internet wave.
  7. Our timeline is in decades, but our customers decide whether or not to stay with us monthly. As a result, we need to have short term operational excellence while maintaining long term vision.
  8. We believe that most of the talent that will change healthcare will come from outside the industry.
  9. The greatest good we can be doing for society is to succeed in our mission. This means we will dedicate 100% of our resources to our mission. We will not get distracted by politics or side missions.
  10. We’re short term pessimistic, but long term optimistic. 

Lore

Creating something from nothing is hard. In the process of creating NexHealth out of nothing, we’ve had many challenges and opportunities, from several near deaths to taking advantage of surprising events that have informed our beliefs, operating principles, and way of working.

Here are a few of the challenges and opportunities that are company defining lores.
  1. Alamin and Waleed started the company with credit card debt and selling things on eBay. No connections to tech, VC, or talent. They took on so much personal credit card debt that Al received a court order from Amex and has a ~600 credit score to this day. 
    Lesson:
    there is no such thing as “disadvantaged” or playing victim. Everything is up to people and their will.
  2. We ran out of money in Q1 of 2018 and survived by convincing a big customer to pay upfront. We reduced headcount from 12 to 4, turned cash flow positive, and grew bootstrapped for the next 18 months. Our product got a lot better, and we grew faster with 4 people than we did with 12 people.
    Lesson: most hard things need to be willed into existence. More money and more headcount is not always the solution.
  3. When the pandemic hit, all of our customers shut down. We stopped charging them to do what’s right for our customers. Our revenue went to 0 overnight. So did our competitors’. Competitors did layoffs, turned off marketing spend, and most sold to PE. While our competitors went into defense, we went on offense. We raised $15M series A in April 2020 while the whole world was shut down, increased headcount, and also acquired Enlive in 2020. It set us up for amazing long term success. 
    Lesson: there is no such thing as a crisis, it’s all about the decisions you make and how you react.
  4. In 2018 we signed on The Smilist with only 4 people. Our largest customer at 18 offices at that time. We had to write a new integration for Dentrix Enterprise in less than 3 weeks, onboard and train their offices, and support them with only 4 people. But it ended up being one of our pillar logos in the dental space that gave us credibility to grow in the space. 
    Lesson: do the things others are not willing to do, like pulling multiple all nighters to sign a pillar customer.
  5. Many experts told us NexHealth would never work. Especially in times when we ran out of money.
    Lesson: in a changing world, experts are almost always wrong, especially when you’re creating something new that experts have not seen before. Experts being negative on your new creation is often a sign whatever you’re creating has value.
  6. Every year there’s a new EHR system that tries to shut us down. And always fails because the customers are on our side.
    Lesson: in order to drive change you have to be able to align incentives. The EHR companies are generally incentivized to keep their customers happy. As long as the customers are on our side, they can’t stop us.
  7. When Bobby closed his first deal in 2018 as an account executive, Al bought Bobby Allbirds shoes. To Bobby this was such a symbolically important moment that he bought our next sales rep shoes on their first deal closed. And this tradition has generally continued. 
    Lesson: celebrations are important for culture.
  8. We hosted the Chainsmokers – NexHealth investors – at our first ever company offsite. 
    Lesson: it was symbolic and recognition that NexHealth is just not another vertical SaaS company like our competitors are. We’re here to change the world, and our standards are a lot higher.
  9. We tried to integrate with an EHR  as one of our early integrations by getting API access. They told our customer that NexHealth will not get API access and that the EHR can offer similar features that NexHealth did. This happened often enough that we decided to find technological ways to exchange data that didn’t rely on an EHR’s API.
    Lesson: do the things others are not willing to do to solve problems.
  10. We acquired Enlive as a series A stage company, about 50 people, no finance team or in-house lawyers, while the world was still reeling from Covid Q3 2020. And most of our investors were questioning it. Acquisitions are not something companies at this stage should be doing. It ended up being company defining for us. 
    Lesson: think in first principles. Do whatever it takes to solve problems regardless of optics or what you’re “supposed to do.”
  11. We raised our Series C a few months after our B. Most investors were questioning it and didn’t see the need for it. However, we’re in an amazing position now because we timed the raise so well. 
    Lesson: think in first principles, don’t just listen to experts.
  12. We bet on Packy McCormick, an up and coming blogger, to do a long form post on us as part of our Series B PR. This long form piece has become one of our greatest recruiting tools. 
    Lesson: bet on trajectory and potential, not experience alone. 

Nexer Experience

In order for us to succeed in our mission, we need to become a go-to destination for smart and ambitious people. However, not everyone will be a fit for our space, product, and culture. So we need to cultivate an experience that filters out the people that are not a fit for us, and retain the people that are.


Who is a Nexer?

A Nexer is missionary, driven, and intelligent with a growth mindset. They build for the long-term, desire greatness, can problem solve and learn quickly, and are not so arrogant that they are not willing to change.

As long as they get to work on challenging problems, build lasting things, learn a ton, and grow as individuals, they are happy. They’re not entitled. All they care about is performance and find great satisfaction in a job well done.

Recruiting: how does a Nexer hear about us?

We need to build our employer brand so that ideally a future Nexer hears about us from another Nexer. The secondary way a potential Nexer should hear about us is internal recruiters or agencies. Once a potential Nexer does hear about us, they should have ample public content and information available to learn what it’s like to work at NexHealth.

How do we interview?

Hiring managers are trained on our principles, phone screen questions, and have done the IC’s job in a previous role so they can properly assess the candidate’s skills. On the phone screen, in addition to their job skills, we’re looking to see their fit by assessing their missionary quality, drive, intelligence, and growth mindset.

Interview participants
All interview participants will be trained by people operations on our principles, interview process, and are high performers and who’s a culture carrier. Managers must get people ops’ approval to introduce new Nexers into the interviewing process. And for people ops, before they send a Nexer to start interviewing, the Nexer should have a 15 minute session with Al, scheduled by the Nexer once training is complete.


Candidate rejection

We want all candidates to be able to say that interviewing with NexHealth was a positive experience, and rejecting candidates should be done as tactfully and respectfully as possible.   

Offer

Every candidate should have earned a universal yes from all interviewers, one of which should be a strong yes, before moving forward. 

Offer signed

Once the offer is signed, managers will congratulate the candidate and express their excitement by sending an email to the whole team with the new Nexer cc’d so the team can give them a warm welcome. Managers will check-in with the new Nexer leading up to their start date to ensure they feel properly supported and have realistic expectations for their first day.

Onboarding

Nexer onboarding is an opportunity to welcome Nexers into our culture and set expectations and context - both what we expect of them, and what they can expect from us. 

Onboarding incorporates a wide range of components to ensure Nexers have the right amount of knowledge and resources to make an impact in their roles on Day 1. This requires effort, planning, and preparation by both the people operations team and the new Nexer’s manager.

Company wide onboarding will include:

  • Company onboarding (facilitated by people ops) will be 1 day in duration and will be inclusive of all items from these operating principles, beliefs, and lore. 
  • We’ll also run monthly sessions with Al and a few of the leads.
  • Managers prepare an onboarding doc that outlines the new Nexer’s first 30, 60 days - including goals, projects, and outcomes (as metrics based as possible). 
  • Nexer and manager align on this plan in every 1:1 to mark progress, identify blockers, manage expectations, and surface frequent feedback.
  • Nexers are expected to visit a customer within 2 weeks of their start date.

1:1s

1:1s between managers and Nexers are critical opportunities to drive alignment and productivity. They are also opportunities to surface feedback and help high performing Nexers build their career plan at NexHealth.

Every manager needs to facilitate a 1:1 with each of their reports every week. Managers proactively book the calendar invite (make it modifiable so the Nexer can move it if needed), but it should be the individual Nexer who drives the conversation. Managers prioritize 1:1s and don't reschedule them, though individual Nexers can if they like. 

Managers will be assessed for efficacy through skip-level feedback conversations facilitated by department heads, and they will also be assessed based on the employee engagement survey results.

Contributing to day-to-day work

As Nexers exit the onboarding phase of their tenure, they will get into a rhythm and deliver on their day-to-day responsibilities. It’s a manager’s duty to ensure Nexers feel motivated and autonomous in pursuit of their goals. They should feel included in the team environment, and have clarity on their priorities.

Defining high performance 

High performance is made up of 3 things: speed, quality, and quantity. In other words, your ability to get a lot done in a very short period of time in high quality is the definition of high performance. At NexHealth, you should be able to get things done 2-3X faster and, 2-3X higher quality than what you’d consider normal for yourself.

Performance Management

At NexHealth, we strive to foster a culture of continuous feedback, which means that we will not have checkpoints for formal performance reviews. Instead, it’s the expectation that managers are providing feedback (both positive and negative) to Nexers in real-time and in weekly 1:1s. We believe this will accelerate our growth and innovation while building trust across the organization.

Our work as Nexers is constantly being evaluated, and promotions and exits could happen any time. Although, neither should ever come as a surprise to Nexers as managers are providing continuous feedback in real-time and in 1:1s.

Internal Transfers

We celebrate Nexers who seek to solve problems outside their immediate scope. Not only will this accelerate our growth, it will help retain our top performers. Generally, Nexers need to be in their initial hired role for a minimum of 9 months. Only top performers will be eligible for internal transfer. Each Nexer who is interested in an internal department transfer will need to interview for the role and have their manager’s endorsement.

Nexers are in charge of their own careers and are the ones to initiate the conversation. Managers are expected to play a strong supporting role in setting expectations, and preparing Nexers for these opportunities. When a Nexer is offered the new opportunity, the new Hiring Manager and current Manager will align on a start date. That date should not exceed 30 days from role transfer acceptance. 


Resigning

Our goal for tenure at NexHealth are high performers stay >6 years, and low performers stay <6 months. Whenever a Nexer does resign, we want them to be a champion for our brand. We want to give them the best experience possible on the way out.

Endnotes

Amazon has “your margin is my opportunity.” At NexHealth, we have “your talent is my opportunity.” 

Most of our competitors in the space suffer because their teams do not maintain high quality or hold a high bar for performance. They have good products with clear market needs, but an inability to execute and scale into leading market share because they don’t retain high performers or maintain a compelling culture.

We have a great vision, differentiated product, we’re well capitalized, and have high growth. However, all of this is eventually copy-able by competitors. The only way we achieve our mission is through our talent and culture. And when we do achieve our mission of accelerating innovation in healthcare, the world will be a far better place than it is today.