Garry A.

Gross
Case Project
ORGD 6020
SPR 2014

The MetroHealth Physician-Administration Compact
Introduction

The MetroHealth System is one of the largest, most comprehensive health care providers in
Northeast Ohio, serving the medical needs of the Greater Cleveland community since 1837.
The organization is proud of its commitment to responding to community needs, improving the
health status of the region, and controlling health care costs. As a public healthcare system,
MetroHealth holds as a core value the provision of services to any resident of Cuyahoga
County, regardless of ability to pay. Utilizing its 400 primary and specialty care physicians
across 17 locations, the organization is dedicated to improving the health status of all citizens of
Cuyahoga County. (www.metrohealth.org)

In light of healthcare reform, and other sweeping changes in the healthcare market, MetroHealth
has endured numerous macro and micro-level changes. After the financial recession of 2008,
MetroHealth, like many other organizations, was forced to make many difficult decisions to stay
afloat. These changes included 2 rounds of layoffs and the procurement of a consulting group
to evaluate all revenue-generating departments in order to improve efficiency and effectiveness
with the goal of increasing revenue. This consulting group designed an efficiency plan coined
the ACCESS Campaign that was implemented across the organization.

Additionally, the consulting group also formed a multi-disciplinary steering committee of leaders
from various departments in the organization to assist with the deployment of the changes,
many of which were being met with great resistance from the employee base. This team
traveled to Virginia Mason Hospital, a similar-sized public health provider that was able to
recover successfully from a similar decline. The committee walked away with several best-
practices from Virginia Mason, one of which was a Physician-Administration Compact.

A Physician-Administration Compact serves as a psychological contract, of sorts, between the
physicians and administrative staff of the institution. It is traditionally a list of gives and gives
from each side that establishes expectations for both groups. These types of documents are
increasingly prevalent in healthcare environments as physicians are being held to higher
organizational standards, differing greatly from the past when each physician had more
influence on his/her own practice.

Holly Perzy, MD, subcommittee chair of the Steering Committees physician relations team, was
tasked with the responsibility of bringing such a document to fruition at MetroHealth. With the
approval of the systems Interim CEO and the Board of Trustees, she hired Jack Silversin, an
expert in the creation of these documents (and the consultant who led the effort at Virginia
Mason) to guide the process. Because of MetroHealths financial constraints, Jack adjusted the
contract to meet the organizations financial capabilities. One concession in the contract was
that Jack, who is located in Baltimore MD, would limit his travel to Cleveland, and would instead
work remotely on the project.


The Process

In their first telephone meeting, Jack lays out for Holly the framework he has developed to
implement the Physician-Administration Compact methodology to organizations. He explains
that each step is vital to the success of the initiative; as its goal is to create a joint sense of
ownership in the document that will, as a result, increase both accountability and acceptance.

The stages Jack laid out are as follows:
1. Airing-out Session - A selected group of physician leaders and administrative
leaders will attend a facilitated 3-hour session during which any old grievances and
negative perceptions each group has about the other can be laid on the table and
addressed. The consensus after the session will be that the past will be left behind and
a new future is on the horizon.
2. Form a Writing Team a group of 8-10 individuals, composed of members of both
groups will be formed to conquer the task of writing the document.
3. Socialize the Draft Every physician and all administrative personnel at the hospital
must read and have an opportunity to weigh in on the document. To achieve this, a
series of facilitated feedback sessions will be held to obtain input.
4. Revise the Document based on the information obtained from the feedback sessions,
the writing team will re-write the document taking those suggestions in consideration.
5. Socialize the Final Draft provide an opportunity for all physicians and administrative
staff to re-evaluate the document to ensure their suggestions and concerns were
addressed. Provide a forum for feedback.
6. Final Revision the writing composes a final document based on any additional
feedback.
7. Signing and Implementation Although it is not an official contract, there is a
ceremonial signing of the document by all physicians and administrative staff of the
organization. This is to both celebrate the creation of the co-created document and
symbolize the agreement of each individual to uphold the requirements of the document.

Holly agrees to the implementation process and is excited about moving forward. Because the
amended contract only allows limited travel for Jack, Holly asks Pamela Ziss, Director of
Organizational Development for MetroHealth, if she will assist. Holly explains to Pamela that
Jack is leading the process and that she only needs Pamela and her staff to assist with the in-
person facilitation tasks. Recognizing that this process can be of great use to the hospital and
that it is gaining political momentum in the upper ranks of the organization, Pamela agrees.


Implementation

After several preparatory meetings and discussions with Holly and Pamela, Jack arrives at
MetroHealth to conduct the Airing Out session. In spite of the amended contract, the three
agree that it is important for Jack to facilitate the first session. The session is well-attended,
with the participant list including the Interim CEO and the Chairman of the Board. The session
was a success, each group had a chance to put misconceptions about their group to rest and
the group collectively agreed to leave the past behind and moved forward. Additionally, the
writing team is formed and the groups meeting dates are determined. Immediately after the
meeting, Jack returns to Baltimore.

After the writing team completes the first draft, Holly reaches out to Pamela to conduct the
feedback sessions. Unaware of the format of these sessions, Pamela reaches out by e-mail to
Jack to inquire about how the sessions should be facilitated. After a week and a follow-up e-
mail to Jack, Pamela receives the following response:

Pamela,
In short, there is no set design for the session, each client is different and the process is
usually tailored to each client. It was my understanding that you would be handling the
feedback sessions. I would be glad to review your design ideas.

Best,
Jack

It becomes clear to Pamela that she and Jack have two different ideas regarding what her
responsibilities are in the process. However, Pamela works with her team design the sessions
without addressing the misunderstanding. The design they construct is as follows:

Welcome video from Interim CEO (10 min)
Review of compacts from other organizations (10 min)
Review of draft/feedback (30 min)
Wrap-up/next steps (10 min)

In order to reach all of the organizations physicians and administrative leadership, the team
decides to schedule 64 one-hour sessions with no more than 15 people in each group. Though
this will stretch their capacity as a group, they recognize that with a small group size, everyone
will have the opportunity to have his/her voice heard. There have also been identified
Ambassadors, both physicians and administration, to assist with facilitating the sessions.


Feedback Sessions

As news of the compact begins to spread throughout the organization, many are anxious to
share their feedback on the document. The first session, facilitated by Pamela and a physician
ambassador, foretells the future of the feedback sessions. During a highly emotional, near-
confrontational session participants (particularly from the physician) angrily voice their concerns
about the document, the ACCESS Campaign, the leadership changes and any other topic of
concern in the organization. Despite Pamelas efforts to use facilitation tactics to keep the
group on the task at hand, the group continues to vent and escalate to the point of yelling.
Future sessions, though perhaps not as volatile produced similar results.

Common themes from the feedback sessions were:
The ACCESS Campaign has put unrealistic expectations on the physician group. The
compact is seen as another way to increase the responsibility of Physicians
Physicians are already meeting and exceeding their end of the bargain. Administration
is the issue
Administration is not transparent, Physicians are not in the loop when it comes to the
business operations of the organization
Administration believes that the physicians are unreasonable and hard to work with
Both groups unclear about why such a major undertaking (compact) is taking place while
there is no permanent CEO in place

The facilitators for each session were receptive of all feedback, and made every effort to convey
that feedback to the appropriate parties. The facilitators also assured the participants that their
feedback regarding the compact would be considered and that they would be able to see and
provide input on the final draft of the document.

Apathy regarding the compact process set in quickly. As a result, only 43% of administration
and 12% of physicians attended a feedback session. Although the sessions were
overwhelmingly negative, they did provide enough information to make some revisions to the
document. One of the most instrumental changes was the a redesign of the format of the
document; as opposed to having two separate, seemingly opposing lists of gives, the columns
would be combined and framed as mutual promises. Other suggestions were passed along to
the writing team for revision.


Debrief

After the completion of the feedback sessions, Holly and Pamela met by phone with Jack.
Pamela shared with them the feedback from the sessions and voiced her concern over the
future of the initiative. Jack, surprised by both the feedback and the low attendance data,
shared Pamelas concern. Jack was unaware that there was a simultaneous initiative (the
ACCESS Campaign) that was not well received by the staff. He asserted the need to rethink
the implementation of the initiative, and that, with the purchase of additional consulting hours,
he may be able to come up with a way to increase acceptance of the process.

Holly, under the pressures of both budget and timeline, graciously listen to Pamela and Johns
concerns, but asks the two to proceed with the initially agreed-upon process.



New Leadership

Shortly after Hollys meeting with Pamela and Jack, Akram Boutros, MD is appointed as the
CEO of the organization. He hits the ground running with his first directive to retool the
organizations Mission Statement, Vision, Values and Pillars. He is made aware of the Physician
Compact Initiative and requests a meeting with Holly.

In his meeting Holly, Akram is supportive of the idea of implementing a Physician-Administration
Compact. He has seen the positive effects of such a document in many organizations. He
asks, however, for Holly to hold off on the initiative until after the Mission/Vision/Values work
has been completed, with the idea that the new direction may affect the end result of the
compact.

On July 10, 2013, Holly communicates to Pamela and Jack that the project is on hold
indefinitely.



Compact Implementation

After a January 24, 2014 organization wide management meeting Holly approaches Pamela
and asks her to step aside for a moment. Having not seen each other in awhile, the two
exchange pleasantries and Holly shares that she has great news for Pamela; the Physician-
Administration Compact is being released at the next meeting! Holly goes on to explain that she
and Jack decided to amend the process and use the feedback obtained from the first round of
sessions to create a final document. Additionally, the document will only be signed from the
top levels of leadership from both groups and disseminated downward in each group.
Questions

1. What may be some of the implications of releasing the Physician-Administration
Compact document in the way Holly has planned?


2. As an OD&C consultant, what is your major responsibility, doing whats best for the
client or doing what the client wants? How does that apply to this case?


3. What might you have done differently to ensure the success of this initiative?


4. How well did Holly, Jack and Pamela work together to ensure the success of this
initiative?

Responses

1. As jack stated in the case, one of the major components of the success of this initiative
is the co-creation of the document providing a sense a sense of ownership and personal
accountability. Releasing the document in this manner not only makes it seem like
another directive from senior leadership, it also represents another broken promise to
the physician group as they were promised additional input into the document before it
became final.

2. As OD&C Professionals we have an ethical obligation to make our clients aware of what
we believe and what evidence has proven is the best case in their situation. However,
having been hired by the client, he/she has the ultimate decision making power on the
direction of the intervention. In this case, perhaps Jack could have been a bit more
forthcoming about his concerns; however it was Holly, the client, who made the decision
to proceed.

3. There were signs, early on, that the project was in trouble. In order to improve the
chances of success, any combination of these may have helped:

a. Holly and the organization securing additional funds to have Jack work full time
on the project. As the expert on the process, Jacks presence at all of the vital
events in the process may have improved the chances of success
b. As a consultant, Jack should have done better research on the hospital and other
initiatives in the organization. He may have been able to identify some of the
barriers earlier in the process
c. Holly, Jack and Pamela should have had a clearer understanding from the
beginning of each of their roles and responsibilities

4. Holly, Jack and Pamela all wanted the project to succeed, however their effectiveness
as a team lacked. The communication between them failed early on. Pamela failed to
communicate her discomfort with the process early enough to make an effective change.
Jack, only working half-time was not particularly responsive to the others. Holly,
ultimately, allowed the pressures of timeline and budget to override the expert opinions
of Pamela and Jack.


Appendix A: Completed Physician-Administration Compact Document