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In pursuit of physician/organization linkage.

There are a lot of things to remember about Albert. His German accent and his large gold rings made him instantly memorable. His appearance was slightly imperious, including a three-piece, impeccably tailored suit with just a few more darts and slits than are usual for business in Boston. Albert's manner wasn't exactly arrogant, but he certainly took command of the situation. Then he held onto that command until he had whatever he wanted. Then he left.

That Albert was a psychologist was evident pretty quickly. He was direct and clear about the process he was engaged in. "You won't mind if I take notes" and "I want to ask you a few questions" began almost every encounter. Unlike a lot of consultants, he didn't send an elaborate pre-meeting statement of what the problem might be and what data he wanted to gather. In fact, he deferred all of the staff's questions and insisted on gathering information without giving any context.

After I got to know him, he was quite open with the reasons for his methods. He understood, he said, that if individuals he was questioning knew what the problem he was consulting about entailed, their desired solutions would profoundly infect their presentation of the most objective data. He was clear, he said, that the person he interviewed for data was not his client, or, as we might say today, his customer.

Our requests for consultation had to do with major changes in our organizational evolution from a classical, plain-vanilla staff-model HMO to a full, 31-flavor, integrated managed care system. Albert first came into our system after one of our mergers, when we were trying to integrate two senior management teams from two organizations with very different core concepts of the role of medical practice. The classical staff model was built as a united, integrated system for prepaid insurance and health care delivery. We merged with an HMO built on small group practice entrepreneurship, especially valuing physician ownership of the practice.

Albert started creating a response before anything specific could be conceived. And that's what we used him for. The swath he cut through our organization was wide, and you could hear the sound of his arrival for miles. We asked Albert to come to solve problems for us. As in most consulting situations, we had a pretty good idea of the family of answers we were going to end up with. Like most consultants, Albert knew that we would tell him what the story was, what we thought the answers were. He would put it into his own words, give it back, and charge us for our own answers.

Albert was our consultant, in short visits, over a series of years, around a series of events in the life of a growing, prosperous HMO. The events usually involved questions of how the physician leaders of the organization should be chosen. How should the physicians see their relationship to the corporation? How could the nonphysician management of the organization exercise its responsibility? More than anything, we looked for Albert when we were in distress. Our HMO was doing better than fine, and the overall organization wasn't. Because "distress" was the problem we asked for help about, the answers we got were that we weren't comfortable with our relationships with each other, so no one felt valued, secure, and productive. That seemed like the right interpretation, but there were no action steps, and no changes in the structure were suggested. We got what we asked for, but not what we wanted. In some ways, we got more than we asked for; Albert was clear that changing each other's personalities was not going to happen in the course of "organizational development." Albert's observations sank into the Triangle like pieces of exquisite china. They were perfectly preserved and aesthetically correct but completely out of view.

Company B pursued the problem of organizational structure in a traditional manner. Understanding the importance of the problem and the need for resolution, the company developed and presented a plan for the consultation in a formal manner, including a four-color prospectus. Interviews with senior management, executive and physician, were arranged and prepared for with a set of structured questions. The questions were processed, analyzed, and packaged for return to senior management, together with anonymous, verbatim reports of views and positions. From there, options for senior management were listed and recommendations were made.

With Company B, senior management first formed a very clear idea of the problems that should be addressed by the consultant; we needed a clear diagnosis of the structural barriers to more effective cost management and to physician morale improvement. And we needed to have a realistic set of change options that we could implement. Several of the senior physician executives jointly reviewed this situation before the questions were formulated, and, before Company B was hired, the entire senior executive team was involved. The consulting firm was chosen after a competitive bidding process and a series of presentations from several different consultants.

After Company B had been chosen, the lead consultant called several of us to help him work through the questions before he began the formal process. Those interviews began with questions about what the "real" questions might be and what would help the consultant produce recommendations that would result in achievable changes. These preliminary interviews were conducted on a one-one-one basis. I remember anticipating that a structural change in senior management might help me, then the medical director.

After several cycles of interviews and revision, the report was prepared as planned. The consultant called several of us to suggest that the problems that needed to be addressed were not structural ones, even though he made structural recommendations. The problems, Company B said, were cultural and stylistic. A structure of lines and boxes, with clear, unified authority, would not help solve those problems. His report was powerful, affecting, and reasonable. It disappeared into the Triangle.

Pieces of Company B's nonstructural observations bobbed to the surface months later. As senior managers, we had not been clear about what problem we were trying to solve because we weren't really aware of it. Key clients within the organization disagreed about central structural expectations. Some valued clear, unified authority; some saw a need for shared authority and greater teamwork; some saw management tasks and physician responsibilities as mutually exclusive; and some saw them as inextricably linked.

Later, Company C was hired to consult with us about the same problem: finding a structural solution that would enhance effectiveness. This time, the client was the CEO. That was clear to Company C when it began a new series of interviews with senior physicians and executives. Its task was clarified as being the development of a clear, unified authority structure that would solve the problems of the physician and management structural relationship. The company's expensive overheads and structural diagrams looked like a flatlander's view of a Buckminster Fuller dome. Everyone with senior responsibility for any part of the operation saw a need to defend his or her turf. Everyone negotiated articulately with the consultants. Company C put together a projection of the changes that would be required in the clinical and business operations and of what those changes would produce in terms of cost reductions and practice improvements. It highlighted serious shortcomings in various management and systems areas and linked solutions of those problems to emerging market opportunities.

The consultants, as individuals, said their structural solution couldn't work "politically." But, as a group, they presented a structural solution. The vision of improvement in the output of the operations was seductive in its unstated suggestion that improvement in operations would follow a structural clarification as the spring follows the winter. The structural solution was accepted, then disappeared beneath the waves in a kind of collusive gridlock; no one wanted to give up turf.

Still later, the work of Company C about changes in operations formed the basis for a new strategic and tactical plan to improve productivity and cost performance by innovation, expansion, and breaking out of old mindsets. The CEO's consultation had not solved the problem as he saw it. But as a long-term contribution to the core issues of the business, the work of the consultants forced each manager to plan creatively, to take risks in thinking about new programs. Motivated initially by the need to defend structural "turf," such forced decentralized thinking helped tap a core of creative entrepreneurship.

When I reviewed all of this with my friend, we talked some more about the Bermuda Triangle of medical management relationships. Each of our consultants had held up a different mirror to us, each with its own flaws. Albert's blank screen methodology validated all of our personal warts and flaws but didn't help us formulate actions to take. Company B gave us an encyclopedic compilation of what we already knew but few priorities. Company C identified core organizational opportunities and unleashed a new strategic focus, without charting a roadmap to the structural question it had been asked. More than anything, we learned that management's job is to remove barriers. Consultants don't solve problems. Rather, they help their clients by pointing the way to clearer understanding of roadblocks. None of the cultural, personality, and historical problems are solved. In fact, these are management issues that need ongoing attention rather than "solution."

Morals of the Consultant Stories

* You don't always get what you ask for.

* What you ask for isn't always what you want.

* Consultants don't solve problems.

John M. Ludden, MD, FACPE, is Senior Vice President, Medical Affairs, Harvard Community Health Plan. Brookline, Mass. he is a member of the Editorial Advisory Board of Physician Executive.
COPYRIGHT 1995 American College of Physician Executives
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Copyright 1995, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Ludden, John M.
Publication:Physician Executive
Date:Mar 1, 1995
Previous Article:A positive experience with a consultant.
Next Article:Don't ask the question if you don't want to know the answer.

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