The value circle: a profile of J. Richard Gaintner, MD. (Physician Anger).

THE ARRIVAL OF A CEO generally signifies a major transition, as organizational styles merge and a new culture forms. In April 1997, J. Richard Gaintner, MD, became CEO of Shands HealthCare, the clinical enterprise associated with the University of Florida. He faced the usual complement of internal divisions and conflicts, reflecting an underlying uncertainty about mission, frustration over the lack of alignment among the system's components, and the natural tendency to try to fix blame rather than confront the fundamental changes underway in health care.

He took the helm of a major academic medical center buffered in a college town of about 150,000 in north central Florida. The seismic change of major urban markets and the relatively pristine climate of Gainesville presented a major strategic challenge. Success would depend very heavily on the ability to help people see the predicament clearly, a challenge made more difficult by the fact that Gainesville was just beginning to experience the sweeping change already underway elsewhere. His role was to teach, as well as to lead and manage.

A graduate of The Johns Hopkins University School of Medicine, Gaintner, who turned 63 in February, brought with him years of experience in diverse venues. Before becoming President of CareGroup in Boston, he served as President and CEO of Pathway Health Network, of New England Deaconess, and of Albany (New York) Medical Center. Earlier in his career, he was Associate Professor of Medicine and Associate Dean for Administration at The Johns Hopkins University School of Medicine and Vice President and Deputy Director of The Johns Hopkins Hospital. He spent the late 1960s and early 70s in clinical and administrative positions at the University of Connecticut School of Medicine and as Vice President for Medical Affairs at New Britain General Hospital in Connecticut. He is currently Professor of Medicine Emeritus at Harvard Medical School.

Indigestion of rapid acquisition and development

In mid-1996, Shands HealthCare was a fledgling health services delivery system that included a tertiary care teaching hospital, four community and two specialty hospitals, a network of community providers, and a statewide home care business. It was formed in 1995, when Shands Hospital, the teaching hospital of the University of Florida, acquired the other hospitals and began developing the provider network. Shands Hospital, in turn, had opened in 1958, when the University of Florida College of Medicine was founded as a state-owned institution. It became a private, not-for-profit corporation in 1980, closely tied to the University of Florida, but no longer part of it.

Following the acquisition, relatively few steps had been taken to integrate the community physicians and the faculty, and both groups displayed a wait-and-see attitude toward the whole venture. Shands, like so many of its peers nationally, was suffering the "indigestion" of rapid acquisition and development. Declining reimbursements, the inroads being made by managed care, and market encroachment from competing systems were further stressors.

In this same period, the faculty of the University of Florida College of Medicine, the largest by far among the six colleges that make up the University of Florida Health Science Center, spontaneously organized a survey to assess the faculty's confidence In their leadership. This straw poll pointed a finger not only at college leadership but also at the Health Science Center and at the fledgling integrated delivery network. Such was the mood of the time. Shands and the University were endowed with talent in every hospital and college department and section. The leaders were not without insight into the changes that lay ahead. But an undirected restlessness infected the ranks of faculty, administration, allied practitioners, employees, and others. While everyone could sense encroaching challenges, no one was well positioned at the ideological helm.

In August 1996, the Dean of the College of Medicine resigned, and an interim dean was appointed. Meanwhile, in Boston, Gaintner was deeply engaged in assembling CareGroup, which combined two of Harvard's principal teaching hospitals and a number of community-based institutions. As CareGroup passed its birthing stage, it became clear that the expansive new network would only succeed if the different cultures of the constituent organizations were allowed to reform under a single new aegis. Neither parent could dominate the child. Leadership identified with the past was slowing the pace of coming together. Ironically, Gaintner, a career consensus builder, laid aside personal attachments. Ready for a new challenge, he accepted Shands' offer to become its chief executive.

A complicated leader

On his arrival, it was clear to Gaintner that Shands' fundamental problem was not lack of direction but rather a multiplicity of directions. There was abundant energy, but it needed to be focused and aimed. He began the process of rebuilding as he had in each of the academic centers in which he had been engaged--by listening and encouraging. He saw angst and disenfranchisement, sentiments that characterized not only Shands and the University of Florida Health Science Center, but also the entire establishment of American scientific medicine.

Complicated times spawn complicated leaders. Gaintner's mild-mannered complexity reflects both developmentally acquired attributes--blue collar upbringing, undergraduate philosophy major, physician, businessman, insatiable reader--as well as core personality characteristics--inveterate optimist, empathetic listener, pragmatist, and conciliator. This constellation of attributes underlies a clinical and managerial intuition that blends into an artful style. Gaintner can be frustratingly non-directive and yet persistently challenging. He abhors detail, yet sends every senior report a handwritten birthday card. He fixates on process, yet requires managers to stay keenly attuned to fundamentals--we take care of people, then we take care of business.

An exemplary teacher, Gaintner has long been dedicated to the cause of developing physicians as leaders. In most routine meetings, Gaintner prefers open "around the room" type discussions, which he handles with Socratic ease. Despite the informality of process, he is inevitably armed with scribbled lists of highly individualized--often italicized--notations. He has something in mind for each person in the room.

Gaintner's approach is characterized by consistent, straightforward messages. His skill is honing in on the values and the critical issues upon which complex decisions pivot. He continually returns to the fundamentals, believes in collaboration, meets with everybody (even competitors), and keeps the lines of communication open. He believes that discussion can illuminate common ground. even in the most complicated and contentious relationships: "No matter what the issue or who the disputant, "says Gaintner, "we're both after the same fundamental objective--there's gotta be some way we can work together."

Grounded in values

His core message is a fierce belief that organizations, as well as individuals, must be guided by steadfast values. "The world of health care has been buffeted from all sides," says Gaintner. "These are tough times for health care, and I believe people at all levels of the organization and in all disciplines need the anchor that values provide."

Gaintner's values are competence, compassion, integrity, empowerment, accountability, collaboration, creativity, respect, trust, and excellence. He reinforces the importance of values at every opportunity, reiterating them in meetings and in one-on-one encounters with staff and physicians, including them in every presentation he makes, from the medical staff to community groups to the hospital auxiliary. Gaintner refers to his values message as "getting back to basics," and it does create a sense of perspective, a feeling that there is something larger than this issue, more lasting than the latest dispute. His grounding in values has made an impression on physicians. Recently, a College of Medicine Department Chair wrote to Gaintner, "Thank you for your guidance and your continued commitment to the ten values that I still have written on my office bulletin board."

Another component of the "back to basics" approach is Gaintner's emphasis, in every forum, on the importance of providing value to the patient and his or her family, the purchaser, and the community. His "value circle," now well known throughout Shands HealthCare and the Health Science Center, includes not just the relationship between cost and quality, but also the questions he believes must be continually addressed by clinicians and administrators in evaluating their work: Did we do the right thing? Did we do it well? Did we achieve the desired result? Did we satisfy the patients' needs and expectations? Did we do it for a competitive cost?

Gaintner's focus on value reassures physicians who fear that the executive response to declining reimbursement will be solely about cutting costs. Gaintner showed early in his administration that concern for quality would not get short shrift. One of his first actions as CEO was to re-charter the Quality Committee of the Shands HealthCare board of directors, making clear that its stature and level of accountability would ultimately make it a full counterpart of Shands' formidable Finance Committee. He has supported refocusing the enterprise's quality management on patient populations and has given renewed emphasis to patient satisfaction. He nurtured the adoption of the Planetree model of patient-focused care at the largest of the community hospitals in the network, Shands at AGH.

Focusing on community initiatives to improve health and thus control costs is another Gaintner mantra. As with the emphasis on values, Gaintner's new emphasis on community mission instills a sense of connection to something larger, a context and purpose for the work. "So much of what we spend health care dollars on is preventable," says Gaintner.

"The greatest leverage on health care spending may come from reducing auto accidents, teen pregnancy, domestic violence, substance abuse, and smoking. This would save an incredible amount of money nationwide, as would better management of chronic conditions, which are becoming more important--and more costly--as the population ages. These measures can improve quality of life at least as much as what we think of as the health care system. Physicians need to be educated in a population approach to managing health."

Managed care is not the enemy

While he remains ever mindful of quality in health care, Gaintner does not resent the focus on costs brought by managed care. "Most physicians, especially those who trained some years ago, as I did, never paid much attention to the cost dimension of medicine. But--and I say this to physicians all the time--we now have to live with financial constraints, and that's fine. Every physician can contribute by eliminating unnecessary tests, working to reduce errors, and generally being mindful of costs in day-to-day practice."

Gaintner believes--and continually preaches--that practicing medicine in a cost-effective manner will improve, not harm, the quality of care. He is well versed in the literature on variation, defect rates, and evidence-based medicine. He continually reminds physicians, in groups and in one-on-one encounters, that the same focus on process improvement that reduces costs will almost always reduce variation and improve each patient's chances for a good outcome.

Far from seeing managed care organizations as inherently hostile forces, Gaintner is enthusiastic about the potential for cooperation between physicians working for managed care organizations and practicing physicians. "It's clear that care must be managed, and this will be easier if each side has a better understanding of the other's goals and challenges." He does not believe, however, that providers should become insurers. "Providers have plenty to do that only they can do, without taking on a whole new line of business."

At the same time, he does not allow his belief in the potential of the concepts behind managed care to cloud his judgment when actual practice falls short of those ideals. He readily shares his own frustration when managed care organizations impose arbitrary, shortsighted constraints on physician practice. And it is well known within Shands and the Health Science Center that he is a vocal critic, in a variety of academic and political forums, of illogical regulations and perverse payment incentives.

He misses no occasion to remind physicians that any money saved is money that can be reinvested in improving patient care. But Gaintner is realistic about the potential for cost-cutting in teaching hospitals, readily acknowledging that they cannot achieve per-case costs that are comparable to community hospitals. Teaching hospitals support additional missions, and their case mix is often dominated by complex patients who pose vexing diagnostic challenges or need highly intensive or highly specialized services. Although the competitive marketplace may not yet fully acknowledge these distinctions, academic physicians are reassured to know that their leadership understands these realities, even as they struggle to come as close as possible to market cost norms.

Helping physicians deal with managed care

Gaintner's willingness to face reality objectively is perhaps his greatest asset in helping physicians deal with managed care. He conveys heartfelt empathy with the day-to-day conflicts physicians face. But he does not allow himself the temporary luxury of cynicism, and he refuses to accept negativity and pessimism in others. Rather, he asks that physicians and managers understand the system and develop the capacity to work within it and take responsibility for improving it.

His obvious joy in meeting challenges head-on inspires others to accept reality and move forward. "Dr. Galntner's focus is always on what we can do, not what we can't," says jodi Mansfield, Executive Vice President and Chief Operating Officer of Shands HealthCare. "He never takes a defensive posture, and others follow his example. He embraces issues rather than putting up barriers."

Gaintner's unfailing enthusiasm for the research and teaching, as well as the clinical, missions of academic medicine, and for the capacity of medicine in the 21st century to improve the lot of humankind also raises morale and spurs physicians to look beyond frustrations with the current market. "With the potential for gene therapy, the advances in neuroscience, and new cancer therapies, it's an exciting time to be in medicine," says Gaintner. "The discoveries being made every day in academic medical centers put us on the verge of being able to help people in so many new ways.

"Dr. Gaintner understands the values that attracted many of us to academic medicine, and his excitement about the potential of 'bench to bedside' transfer helps us put managed care issues into reasonable perspective," says Peter Gearen, MD, Professor of Orthopedics at the University of Florida College of Medicine and Chief of Staff for Shands HealthCare.

Meaningful physician participation

Beyond exhorting physicians to be accountable for the success of the enterprise, Gaintner creates mechanisms for meaningful physician participation in enterprise management. He allocates Shands HealthCare's resources, to the extent possible, to support academic departments that are pioneering innovative approaches to patient care. A new Resource Utilization Committee, jointly chaired by senior executives from Shands HealthCare and the College of Medicine, is a true joint effort to examine resource use and to give physicians the responsibility for redesigning patient care processes.

Integrating the planning efforts of the College of Medicine and Shands HealthCare has also bolstered physician participation in shaping the response to managed care and the future direction of the enterprise. The Faculty Group Practice Planning Committee, with representation from both entities, shares decision-making power for all new clinical programs. Recently, the director of planning for the Health Science Center assumed leadership of Shands HealthCare's corporate planning staff, integrating planning at the staff level. Gaintner has also fostered a joint approach to managed care contracting, both for community and faculty physicians.

Gaintner has long been dedicated to developing physician leaders and has strengthened the role of medical directors.

He has set clear expectations for accountability, which drives their compensation for this component of their professional responsibilities. Each clinic has a medical director who is responsible for clinic operations and budget. Gaintner is an astute judge of people and quickly spots potential physician leaders. Once identified, medical directors and other physician managers receive strong and consistent backing from Gaintner.

Given the history of mistrust between the faculty and the clinical enterprise, the emphasis on shared decision-making might be met with cynicism were it not for Gaintner's unprecedented openness about financial matters. He set In motion a 'funds flow" project designed to trace and document all commerce between the Shands enterprise, the colleges of the Health Science Center, and the University of Florida. I feel that my most important contribution so far has been to create an environment characterized by openness, communication, and trust. I believe In letting everyone know what's going on," he said. Gaintner's honesty, integrity, and commitment to knowing and sharing the financial facts have boosted the willingness of faculty physicians to take a proactive approach to the changing market.

Effecting change

Gaintner's leadership role at the national level enables him to keep physicians and staff current with the changing market. In addition to his membership on the board of directors of the American College of Physician Executives, he serves on the board of the American Hospital Association, the executive board of the Association of American Medical Colleges, and is Chair-Elect of the Council of Teaching Hospitals. He is also active in numerous state-level organizations. Dick Gaintner has his finger on the pulse of the market and knows where the industry is heading," says Gearen. "If we were ever tempted to duck reality, Gaintner's insights into what is happening in the markets--and into the trends shaping the future of health care--keep us from being satisfied with business as usual."

In keeping with his proactive stance, Gaintner advises physicians who are unhappy with the current state of health care to get involved in effecting change. "My motto," he says, is 'Don't fix the blame. Fix the problem.' Every individual can make a difference. If physicians want to shape the future, they should get involved in the political process and try to understand it. They should be active in state and national organizations. Physicians tend to be impatient, but, as frustrating as It can be, patience pays off."

Looking ahead, Gaintner wants to ensure that today's medical students have realistic career expectations and are being well prepared to work in a managed care environment. He derives great satisfaction from meeting with the University of Florida medical students to discuss his view on values and value. "I look forward," he says, "to working with the next generation of physicians and am optimistic about their potential for transforming American medicine." With no immediate plans for retirement, Gaintner himself is likely to continue playing a leading role in shaping that future.

RELATED ARTICLE: Helping Physicians Cope with Change

These are disconcerting times for physicians. Where will change lead us and how will it affect the medical profession? The question causes some to throw up their hands in frustration and anger. That's not helpful. We as physicians have accepted some fundamental values upon which our profession is based. It is imperative that we preserve these values if we are to sustain the trust and confidence of those we serve. The better response to change is to recognize ourselves as leaders and strive to create the health care future. That leadership requires vision, participative management, innovation, and investment,

Historically, the prevailing health care model has been service provided by independent or small groups of physicians practicing as autonomous contractors in community hospitals. These fundamental components of the health system have, of course, been complemented by a host of other professionals and para-professionals collectively supporting what could be termed as the "service t transaction." The other player in the health service equation is the third party payer, who provides service through managing the "financial transaction." The service and financial transactions supported one another. The system served Americans well over the years, but clearly change is upon us. Doubts about a prevailing view usually come about with a dilemma. Ours is cost inflation.

Nature of a system

Russell Ackoff (1) describes the nature of a system using human body parts as analogy:

* The behavior of each element has an effect on the behavior as a whole--the heart, lungs, kidneys, and so on impact the body's performance.

* The behavior of the elements and their impact on the whole are interdependent--the way the heart behaves and affects the body depends on the behavior of the brain, lungs, and other parts.

* Elements of the system are so connected that independent sub-groups of them cannot be formed.

The American health care "system" is, in fact, not a system. We continually struggle over elements or sub-groups pursuing independent objectives. Our goal must be to create a true system. Physician leaders must design and operate this new system to improve the health of those we serve.

Aligning incentives

For the sake of simplicity, let us view the health system as comprised of physicians, hospitals, and insurers. Presumably. managing these elements towards common objectives should improve performance. The academic component provides the continuous research and developments that create a learning organization and drive innovative improvement--the basis for an Integrated Academic Health Service Organization (IAHSO). Some propose that the IAHSO model will not work because the incentives of the physician, hospital, and insurers are not aligned. There is a historical basis to support this assumption. but given a vision that requires efficiency, how can we justify competing incentives that impair health system effectiveness?

In addition, Bujak (2) notes that physicians are enculturated in such a way that they are "organizationally impaired." To expect physicians to come together as a true team, serving as the foundation of a health service enterprise, sharing wisdom, promoting innovation, improving service, improving health, and reducing cost just isn't going to happen. Physician leaders must develop an enterprise that aligns incentives among elements of the health system and creates an environment where the exceptional qualities of physicians can add value to performance and sustain our professional values.

Five transformational farces

Further grist for vision comes from J.D. Kleinke, (3) who describes five forces driving the transformation of health care.

These trends are:

1. Consumerism, focusing on the patient's needs and expectations. Information availability and technology will create a highly health service educated consumer and, inevitably, a demanding one. Our emphasis must be on service.

2. Integration. brining together the elements of health service delivery and managing them towards common objectives.

3. Consolidation, resulting from the inevitable redefinition and redistribution of delivery system capacity required by new technology, pharmacological advances, evolving service models, and changing consumer expectations.

4. Industrialization resulting in system and process improvement that reduces variability, improves outcomes. improves service, and reduces cost.

5. Assuming risk, putting physicians in the driver's seat. "It is readily apparent that forward integration by providers into the insurance function is not only strategically likely but inevitable." (3) If the financial transaction is intrusive to the service transaction, what are we going to do about it? Physicians can come together in an IAHSO, evolving best practices and creating economies of scale. Why can't we create the infrastructure to manage and accept accountability for the financial transaction? This would enable physicians to set service price in the market, manage the revenue, influence the consumer through a "customer relationship," and, most significantly have real time access to cost and outcomes information through claims a aralysis in order to improve service. These are compelling opportunities.

Summarized, the vision is a physician-led IAHSO capable and willing to assume and manage economic risk. The service and financial transactions are under common management for the benefit of the consumer/patient. Participative management is required to help others understand and embrace the vision, as well as to focus on innovation. Innovation, in turn, drives investment decision.

Interactive, participative process

Promoting and establishing credibility for the vision begins by continually articulating it. This stimulates discussion, creates understanding, seeks feedback, creates modification, and encourages buy-in. For the leader, the process is arduous. It is particularly demanding because of t e noise in the environment brought about by the economic, cultural, and fundamental challenges of promoting trust in one another and confidence in our ability to succeed.

We must engage physicians in planning and operations. This, too, is a difficult process due to the sometimes sheer numbers of people, the geographic spread in a large organization, and the inevitable variation in interest, understanding, and commitment. There is no expectation of seeking consensus, but suffice it to say, with more and more difficult decisions affecting more and more people, the greater the participation, the greater the acceptance and commitment. Experience has generally supported the adage that reasonable people given comparable information will make similar decisions.

Annual planning should include a plenary session for reaffirming mission, values, and strategic initiatives at an organizational level. Subsets of the organization, such as regional geographic elements and/or clinical specialty groups should conduct forums to identify and prioritize needs and expectations, as well as define tactics that are consistent with organizational strategic e products of the subset meetings should be brought back to plenary session to reconcile and relate tactics to the organizational strategy in such a way that all translates into a feasible, responsible business plan and budget. The emphasis again is on interactive, participative process.

Day-to-day governance requires more of the same. How can we design structure and process to promote interaction and participation? How can we minimize the sense of personal disenfranchisement? Penn State Geisinger is establishing four regional operating councils. In addition, there is an organizational medical executive council, which serves as the senior management decision-making body Standing or ad hoc subcommittees of the executive council evaluate issues and make recommendations the executive council, The goal is to encourage and facilitate the participation of others in the design and planning for the organization. "What is required is that individuals be able to measure their own quality of life, that they have the opportunity to improve it, that they be encouraged to do so, and that their efforts to do so be facilitated." (1)

Innovation and investment are intertwined

Innovation is fundamental for change. Innovation is manifested through research and education--a disciplined approach to examining systems and processes and incorporating change into our daily practices. It is an inexorable part of leadership. Innovation an investment are intertwined. When we talk about investment, we must understand the intellectual capital that goes into research and education and the transfer of knowledge that improves performance. We recognize the financial capital required to support the learning organization and ultimately invest in new capabilities. Cost benefit is most times difficult to quantify, but it is essential that we move ahead. The following s a case in point. (4)

The Penn State Geisinger Health System is a not-for-profit physician-led IAHSO committed to serving the cities and rural areas of Pennsylvania with the best patient care, medical education, and research. It spans two-thirds of the state, serving more than 4 million people in 40 counties. It provides more than 900 primary care doctors and specialists practicing in 90 locations. These physicians see more than 1,8 million patients each year, many in very remote and rural clinics. The System's managed ca e arm, the Penn State Geisinger Health Plan, was the nation's first rural HMO and now has over 260,000 members. This is emphasis on managed care has propelled the entire organization toward preventive medicine and an active pursuit of care coordination.

Helping Physicians Cope with Change

It was from this backdrop and the challenges of rural health, that a small team of senior executives gathered in the Spring of 1995 to focus on the questions of strategically applying technology to improve health. Recognizing the huge investment involved, this team narrowed their target to one significant setting of care, the clinics.

It was recognized that technology alone would not accomplish our goals. Key processes were identified (ordering, clinical results reporting, scheduling, point-of-service billing, utilization management, referrals, and security and confidentiality) and teams assigned from throughout the organization to "redesign" workflow. New clinic process flows were created and the implementation of technology began.

Technology was delivered in multiple phases. Recognizing the extensive change for the physicians, the team determined that prior use of technology might ease the pain and improve acceptance. A first wave of work stations was delivered to each physician's office. Basic microcomputer tools were provided, enabling physicians to begin communicating via email and have access to medical literature, reference materials, and the Internet. A corporate Intranet was refined as an avenue to supply clinical guidelines and other information. These functions, made available in all of our clinical network sites, induced physicians to begin exploring the use of technology.

Physician acceptance varied widely Some adapted immediately, leveraging the technology to improve their workflow. Others resisted, unable to acclimate to the change. None refused, but many found their day extended to accomplish the same amount of work. Data shows that physician satisfaction improved considerably after 12 months of use and there have been significant benefits to improving service and outcomes and reducing costs.

Conclusion

Change dominates the health service landscape, driven largely by constraints on financial resources, which can be likened to depriving a body of oxygen. We, as physicians, are experiencing confusion, irritability, even seizures. Acclimation is necessarily a slow process and our society must recognize that too much deprivation can have a lethal effect on the organism. Given that reality, physicians must first recognize the need to adapt. We must then lead change and at the same time govern its pace. A vision and a process are required that engage us collectively in innovation and investment for a future that continually improves health at a cost that society can afford. It is imperative that physicians step up to the task.

Stuart Heydt, MD

References

(1.) Ackoff, Russell L Creating the Corporate Future. NewYork, NewYork: John wiley and Sons, 1981, p.15.

(2.) Bujak, Joseph S. Can Physicians Lead Other Physicians into the Future? The Physician Executive, September/October. 1998 p. 14.

(3.) Kleinke, J.D. Bleeding Edge: The Business of Health Care in the New Century, Gaithersburg, Maryland: Aspen Publishers, Inc., 1998. p. 35-36.

(4.) Thompson, Patricia. "An Innovative Technology Application in Pursuit of Improving the Health for A Rural Population." Penn State Geisinger Submission to The Second Annual Innovation in Healthcare Information Technology Awards. 1998.

Stuart Heydt, MD, is Chief Executive Officer at Penn State Geisinger Health System in Pennsylvania. He can be reached by calling 717/531-1838 or via email at [e-mail].

Rebecca Howard is an editor and writer living in Gainesville, Florida. She can be reached by calling 352/395-0421 or via email at [e-mail].