Joseph Mack & Associates Alignment Of Organizational Culture To Strategies And Leadership Is A Critical Success Factor For Clinical Integration And Ac Os
Alignment of Organizational Culture to Strategies and Leadership is a Critical Success Factor for Clinical Integration and ACOs Culture Must Match December 2012 Strategies and Leadership How Culture Drives Or- Strategies Must Match Culture and Empower Leadership ganizational Vision and Strategies Alignment of strategies tives. Some organiza- formational initiatives is How Leadership Influ- with organizational cul- tions develop clinical different. In the former, ences Implementation and ture and leadership is integration and ACO strong transactional Management of Organiza- critical to success of approaches that are not skills are often domi- tional Vision and Strate- Clinical Integration and supported by their cul- nant and may be suc- gies ACO objectives. In our ture. Leadership tasked cessful. In the latter, Implementation of Clinical recent work with cli- with implementing inno- one must have strong Integration and ACO Strategies ents developing various vative or “radical” transformational and collaborative strategies strategies within status transactional skills. Critical Success Factors and models we have quo or “conservative” Proper alignment of found substantial incon- cultures face significant strategies to culture, gruity between an or- challenges and greater and of management Inside this Article ganization’s values, risk of failure. Further- style to strategies isCulture Drives Hospital 1Strategies strategies and commit- more, management critical to successful im- ment, and management style required to imple- plementation of clinicalCulture and Integration 3Strategies selected to develop and ment and improve in- integration and ACO guide these new initia- cremental versus trans- initiatives.Traditional Hospital 4Process RedesignLeadership Traits Re- 5quired for Process Re- Understanding Culture anddesign its Impact on Organizational Vision and StrategiesTransactional 5Leadership Influence of Culture on Hospital StrategiesTransformational Lead- 6ership Clinical integration re- successful, these strate- hospitals are by natureHow Leadership Imple- 7 quires departmental and gies must match the or- market survivors. Theyments Process Redesign organizational-wide im- ganization’s vision and are internally focusedApproaches to Clinical 8 provement in functions culture. on such things as qual-Integration and core processes. ity, cost and customerVertical to Horizontal 9 The degree of change The strategies a hospital service. These organi-Redesign required and committed adopts can be charac- zations typically moni-Critical Success Factors 10 to is dictated by the terized into three orien- tor the market for stra-in Alignment of Culture,Strategies and Leader- strategic objectives of tations: survivor, adap- tegic opportunities, butship the organization. To be tor and enactor. Most are less likely to commitCase Study 13
Page 2 Joseph Mack & Associatessignificant resources to their itability generated from inter- their redesign initiatives focusimplementation. Hospitals nal operations to invest in sub- on departmental and organiza-that are market adaptors are stantial, long term, and higher tional-wide improvement.also internally focused. Their risk strategies to dominate Market survivors have an in-strategies focus on short term, their markets. Their strategies trinsic need to be industrious.incremental strategies that can involve evaluating market They improve and transformbe easily changed or aban- trends to adapt to their own their organizations. Figure 1doned. They often develop organizations. Extrinsic moti- illustrates the relationship ofcopycat strategies. They vations create challenges for strategic orientation to opera-monitor the market and market survivors and adaptors tional and clinical redesign.adopt other’s approaches. to overcome inertia withinMarket enactors use the prof- their organizations. Many of Figure 1: Relationship of Strategic Orientation to Operational and Clinical Redesign Organization-wideOrganizationalCulture Drives DepartmentalStrategies andRedesign Focus Functional Core Processes Transformational
Page 3Influence of Culture on Clinical Integration and ACO StrategiesStrategies must match vision. tivity within their organiza- and physicians from outsideAs Figure 2 illustrates, long tions. of their medical centers interm strategies with bold ob- performance improvementjectives are radical and trans- As an organization begins initiatives.formational. Short term, con- to move further towardsservative goals produce incre- becoming a market adaptor, Market enactors focus onmental successes. As most while still largely focused longer term, higher risk initia-hospitals are by nature market redesigning functions, more tives that fundamentally re-survivors, operational and initiatives begin to incorpo- design operational and clini-clinical redesign efforts tend rate cross-functional partici- cal processes. They developto be hierarchical. Most ef- pation, and to implement larger, more complex collabo-forts are focused on func- more core process redesign rative strategies frequentlytional departmental improve- efforts. The organization involving internal and exter-ment. To the extent cross- begins to transition from nal constituencies.functional initiatives occur, vertical to horizontal proc-they are focused on cutting ess improvement, and begincosts and improving produc- to involve organizations Figure 2: Influence of Strategic Orientation on Operational and Clinical Redesign Strategies Organization-wide Most hospital cultures support short term, incremental redesign strategies, Departmental rather than longer term radical initiatives Functional Core Processes Transformational
Page 4 Joseph Mack & Associates Traditional Strategies for Hospital Functional and Core Process Redesign An organization’s vision af- level. Some departmental func- on functional departmental and fects its emphasis on opera- tional improvement involves organization-wide outcomes tional redesign. Hospitals are high opportunity core proc- are fundamental, necessary, constantly improving depart- esses that begin to encourage and beneficial. Organizational- mental functions. Some of cross functional participation wide core process improve- these initiatives are imple- throughout the organization. ments are transformational. mented throughout the or- The greatest impact for redes- Figure 3 illustrates the ganization and provide ign efforts are initiatives fo- strengths and weaknesses of greater impact than focusing cused on organizational-wide the various redesign ap- only at the departmental core processes. Efforts focused proaches. Figure 3: Comparison of Traditional Functional and Core Process Operational and Clinical Redesign Strategies Functional Organization-wide Departmental Process Improvement is Fundamental. Organizational- Departmental wide CoreProcess Redesign isTransformational Functional Core Processes Greater Impact
Page 5 Understanding Leadership and its Impact on Implementation and Management of Organizational Vision and StrategiesLeadership Traits Required for Functional and Core Process Operational andClinical RedesignOperational and Clinical Re- transactional and transforma- plementary and interdepend-design occurs along a contin- tional leadership. The differ- ent to the transactional style.uum from conservative to ence between transformational Transformational leaders mustbold; from a focus on func- and transactional leadership lies also employ transactionaltional to core process im- in the way of motivating others. skills. On the other hand,provement and change; and Transactional leaders work transactional leaders tend tofrom improvement to trans- within the organizational cul- have little or no transforma-formational. ture as it exists. The transfor- tional traits. On this end of mational leader changes the the continuum, transactionalResearch on leadership sug- organizational culture. leadership is independent ofgests two factors to differen- The leadership continuum is transformational skills.tiate “ordinary” from illustrated in Diagram 1. Trans-“extraordinary” leadership: formational leadership is com- Ordinary Leadership is Transactional. Extraordinary Leadership is TransformationalTransactional LeadershipTransactional leadership fo- managers. It focuses on the ba-cuses on clearly defined goals sic management process of con- Transactional leaders are effec-and tasks, works within the trolling, organizing, and short- tive in guiding efficiency deci-existing organizational cul- term planning. Transactional sions which are aimed at cuttingture, incentivizes staff to leaders emphasize detailed and costs and improving productiv-achieve goals through re- short-term goals, and standard ity. These leaders tend to bewards and punishment, and rules and procedures. They rely highly directive, task and actionmotivates achievement little on enhancing followers’ oriented.through appealing to em- creativity and generation ofployee self-interest. This new ideas.style is most often used by
Page 6 Joseph Mack & Associates Transformational Leadership Transformational leaders focus transformational leadership the intention of allowing them on adapting to non-routine when adaptation is the goal. In to reach higher levels of situations, and on changing the these scenarios, it is critical that achievement than might other- organizational culture by creat- the leader be a change cham- wise have been achieved. Indi- ing new ideas. These leaders pion who can assemble and mo- vidualized consideration plays a motivate others by broadening tivate a group with enough key role in neutralizing the in- and elevating their interests, power to lead the change. evitable resistance that is generating awareness and ac- bound to accompany the trans- ceptance of the purposes and A transformational leader pro- formational process. The mission of the company, and motes the creation of a culture leader must work at getting stimulating employees to look that encourages team-decision large numbers of people in the beyond their own self-interest making, and provides individual organization involved in the for the good of the group. consideration to the specific, transformation process. Oth- unique needs of their staff to erwise, it is likely to be greeted Transformational leadership is ensure they are included in the with cynicism and strong resis- better for non-routine situa- transformation process of the tance from key constituents. tions. Whereas transactional organization. People are leadership is well suited to im- treated individually and differ- Table 1 compares transactional proving efficiencies, organiza- ently on the basis of their tal- to transformational leadership tions are more receptive to ents and knowledge and with characteristics. Table 1: Characteristics of Transactional and Transformational Leaders Transactional Leadership Transformational Leadership Leadership is responsive Leadership is proactive Focus on maintaining status quo and achieving specific Focus on adapting to non-routine situations goals Transactional Works within the organizational culture Works to change the organizational culture by implementingleaders manage new ideas Transactional leaders make employees achieve organizational Transformational leaders motivate and empower employees and improve objectives through rewards and punishment to achieve organization’s objectives by appealing to higher status quo. ideals and moral values Motivates followers by appealing to their own self-interest Motivates followers by encouraging them to transcend theirTransformational Emphasizes clarification of goals, follower compliance own immediate self-interest for the sake of the mission and leaders change through incentives and rewards, with a focus on task vision of the organization culture completion Emphasizes understanding of the importance of task Followers’ compliance (effort, productivity, and loyalty) is outcomes exchanged for expected rewards Followers are encouraged to think critically and seek new ways to approach their jobs
Page 7Impact of Leadership on Functional and Core Process Operational and Clinical RedesignStrategiesAn overview of the impact of process improvement efforts. organizational-wide functions,transactional and transforma- Since the transformational often to the exclusion of crosstional leadership on operational leader also has transactional -functional core process re-and clinical redesign strategies skills departmental and organ- design. Transformational lead-is illustrated in Figure 4. Trans- izational wide functions are also ers achieve radical change.formational leadership fits well improved. Transactional lead- Transactional leaders achievewith organizational-wide core ers focus on departmental and incremental change. Figure 4: Overview of the Impact of Leadership Style on Operational and Clinical Redesign Strategies Transactional leaders Organization-wide motivate by appealing to employee self- interest. Transformational leaders stimulate Departmental employees to look beyond their own self- interest for the good Functional Core Processes of the organization. TransformationalFigure 5 illustrates the influence of leadership powering teams and individuals to transcend thestyle on functional and core process opera- status quo through organizational-wide radicaltional and clinical redesign. Transactional lead- transformation.ers tend to focus more on functional improve-ments. Transformational leaders, while focus-ing also on functions, tackle core process re-design. They inspire their organizations by ef-fectively communicating the vision, and em-
Page 8 Joseph Mack & Associates Figure 5: Influence of Leadership Style on Functional and Core Process Operational and Clinical Redesign Transactional Organization-wide leaders tend to focus more on functional improvements.Transformational Departmental leaders tackle core process redesign Functional Core Processes Greater Impact Implementation of Clinical Integration and ACO StrategiesApproaches to Clinical Integration Clinical integration occurs along ships and pay for call that are models that may move the or- a continuum from targeted ini- targeted to improve certain ganizations further along the tiatives by a hospital and a sub- clinical areas or processes are continuum towards clinical in- set of its voluntary medical staff “basic” forms integration. tegration. Integrated delivery to address a particular clinical Independent Practice Associa- systems, ACOs, and physician condition or procedure, to in- tions (“IPAs”), Management owned hospitals focused on tegrated delivery systems Service Organizations patient centered care are the where hospitals and medical (“MSOs”), Physician Hospital most sophisticated models groups are under one umbrella Organizations (“PHOs”), and aimed at achieving financial and organization, and physicians are Specialty Institutes are exam- clinical integration. employed. Medical Director- ples of structural and financial
Page 9Clinical Integration and ACOs Demand a Shift From Vertical to HorizontalRedesignAs Figure 6 illustrates, the medi- paradigm shifts. As has been emphasis on horizontal redesigncal home approach conceptually previously discussed, much across organizations to improvedemands a shift from vertical to redesign historically has oc- system performance. Essen-horizontal operational and clini- curred vertically within a par- tially, the organizations arecal improvement to optimize ticular institution. Ideally, turned 90 degrees so that vitalsuccess of patient centeredness these efforts extend horizon- processes are emphasized,and population health manage- tally as well in order to gar- rather than sites of care.ment objectives. When two or ner the most cross-functionalmore organizations are in- involvement of staff and corevolved, such as hospitals and processes. Patient centeredphysician organizations, the care requires an increased Figure 6: Comparison of Vertical and Horizontal Approaches to Operational and Clinical Redesign Hospital and Health System ACO and Clinical Integration Hospital Hospital Medical IPA Hospital Hospital Medical IPA 1 2 Group 1 2 Group Medical Clinical Support Admin. Medical Mgmt. Ops. Services Services Mgmt. Maximum Realignment & Core Process Redesign Patient Centered Care Some Cross-Function Realignment Management Requires & Core Process Redesign High Opportunity Areas & Processes Clinical a Shift in Focus from Ops. Vertical to Horizontal Support Services Redesign Support ServicesThe success of the approach used is dependent upon the culture and leadership of the organizationto create, implement and manage the selected initiative. While structure is important, especially tomitigate legal and business risk, alignment of organizational culture and leadership with clinical inte-gration and ACO strategies is critical..
Page 10 Joseph Mack & Associates Critical Success Factors in Alignment of Culture, Strategies and Leadership to Clinical Integration and ACO InitiativesFigure 7 compares culture, in- empowered to improve existing alignment of strategies andternal and external strategies operations or transform the cultural orientation. As hasand leadership. To be success- culture. Misalignment of or- been discussed, there is someful, strategies must match cul- ganizational objectives to lead- cross-over between leader-ture. As an organization moves ership style may inhibit success- ship characteristics and inter-further along the clinical inte- ful implementation and manage- nal clinical redesign efforts,gration continuum it must have ment of strategies. particularly from transforma-the infrastructure and proc- tional to transactional. Simi-esses to promote evidence- The roles and columns in Figure larly, a market adaptor organi-based medicine and patient en- 7 illustrate the alignment of cul- zation may employ skills fromgagement, report on quality and ture, strategies and leadership both types of leaders, depend-cost measures, and coordinate to one another. Typically, ing on degree and breadth ofcare. Leadership must match there is little if any diagonal its internal and external strate-the organization’s values, and be gies. Figure 7: Alignment of Strategies to Culture and Leadership Who Are We? Where do We Want Survivor Adaptor Enactor to Go? Strategies must How Do We Get There? Culture Low Risk Medium Risk Higher Risk follow culture. Lead industry Incremental Adapt to structure, Strategies focused on Leadership must be capitalize on all infrastructure & opportunities standards, & change customers empowered by Transactional Transformational culture. Departmental Variance and cost reduction Service and Value Enhancement Does Culture Functions Match Our Reducing avoidable, Work is redesigned to Intent? Organizational unproductive and consolidate roles into new Functions duplicative services and different configurations Does Culture Treatment in the Work is realigned around Empower or Departmental optimal setting by the care complexity and Prohibit Core Processes right provider optimal patient flow Leadership Organizational Improving Patient Work redesigned shifting Success? Experience focus to preventive care Processes and population health
Page 11Table 2 illustrates the critical success factors, and common causes for failure of alignment of cul-ture, strategies and leadership in developing clinical integration and ACO strategies. An organiza-tion must take an honest look at its own culture to determine the classic strategic questions: whoare we; were do we want to go; and, how do we get there. Everything else flows from and is sub-servient to culture. If the strategies selected conflict with culture then they will fail, unless cultureis transformed. There are leaders whose expertise is transformation. Others concentrate on im-provement within the organization. Culture either enables or hinders their success.Table 2: Critical Success Factors and Common Causes ofFailure in Alignment of Culture, Strategies and Leadership Strategies that are misaligned with culture will fail. Unless empowered by culture, leadership will fail.
Page 12 Joseph Mack & Associates Case Study ExampleIn our recent experience with several clients developing clinical integration and ACO strategiesthere has been little or no discussion of the alignment of organizational culture, strategies andleadership. Culture receives only general comments, sometimes referencing the organization’smission and vision, reputation in the marketplace and executive leadership. Strategies are oftenstated with somewhat more precision, especially when they mention such things as to become aCenters for Medicare and Medicaid Services (“CMS”) ACO, create a risk bearing organization,etc.By contrast, leadership responsibilities are often described in significant detail. The following isone example: “…responsible for administering the overall policies and procedures related to the care coordi- nation and integration of patient care activities across the continuum of care. … responsible for ensuring optimal, achievable and sustainable standards of care, maintain- ing positive staff morale, and promoting cooperation between patient care services and other hospital departments, medical staff and physician organi- Alignment of zations. In conjunction with the Executive Leadership Team, is accountable strategies and for strategic planning, setting priorities, allocating resources, quality assur- ance and building strategic partnerships to improve care coordination leadership to across the system.”culture receive Organizations are similarly detailed about desired leadership experience and little if any skills. Profiles focus on such things as understanding hospital functions and attention processes; role of physicians, especially hospitalists; finance, especially man- aged care; quality; population health/coordinated care; outcome improvement and care redesign; information technology; etc. Leadership traits mentionedinclude vision; communication skills; integrity; strategy; influence; reputation and trust; courageand forthrightness; ability to inspire, including strong change management and problem solvingskills, able to identify obstacles and solutions, demonstrated success in building teams and reducingsilos, and demonstrated success in developing team champions.Organizations must honestly ask themselves: does our culture match our intent; and, does cul-ture empower or prohibit leadership success? Is it reasonable that we will go from little or nointegration to collaboration, and in what time? It is important to have lofty aspirations. It is moreimportant that they are realistically supported by culture.All of the organizations we work identify, among other traits, that they want inspirational leadersto develop and manage these strategies. However, when culture is misaligned with strategiesleaders are inhibited or prevented from successfully deploying charisma and motivation that en-
Page 13courages innovation and creativity. Development of and evangelizing the vision of the“redesigned” organization and the clinical integration approaches is impossible. Unless values areclearly understood and shared among all those who work together, intense commitment and im-plementation success is impossible. Proper alignment of strategies to culture, and of managementstyle to strategies is critical to successful implementation of clinical integration and ACO initia-tives.Case StudyBackgroundWe recently worked a multi-hospital system with over 30 clinic and outpatient centers dispersedover a large geographic area. Over a year previously, the system had acquired two large physicianorganizations and placed them into a medical foundation (“Foundation”). The physician enter-prises consist of a large medical group, and an independent practice association, physician practiceconsulting and Medicare Advantage insurance agency. The organization is an approved Account-able Care Organization. Together, these organizations represent over 600 employed and con-tracted primary care and specialty physicians. In addition, they contract with over 1000 additionalphysicians through managed care agreements.The system’s strategies include market differentiation and growth, improvequality and value, improve profitability, partner with physicians, governance and Partnering withleadership, and develop people and culture. physicians forGoal #1 alignment acrossThe first goal was to consolidate and streamline the operational and clinicalroles and functions of the two acquired physician organizations to improve effi- the system is notciency and profitability. The health system had acquired each of the organiza- fully supportedtions over a year previously, but had not “merged” them together. The initialobjective was to improve the efficiency and profitability of the combined busi- by cultureness.ObservationThe strategies to create the Foundation and acquisition of the two physician organizations are con-sistent with what one would expect from a market adaptor or enactor.To ascertain more clearly an organization’s cultural orientation, it is informative to examine howthe strategies are actually executed, and whether the particular objectives are achieved. Develop-ment of population health and partnering with physicians across the system, among others, arestated objectives. Integration of the two physician organizations had not occurred several monthsafter acquisition. Each had its own leadership, functions and processes. The Foundation held a se-ries of meetings with Foundation and system executives and a “leadership consultant” to brain-storm on the desired skill set of the of the Foundation’s Chief Executive Officer (“CEO”).
Page 14 Joseph Mack & AssociatesFindingsStreamlining the operational and clinical roles and functions of the two acquired physician organi-zations, from the systems perspective, is transactional rather than transformative. Other thanprofitability, it has little bearing on the system. Creation of the Foundation, and its physician ac-quisition strategies appear to be copycat strategies, which are indicative of a market adaptor. Wewould expect organizations with this orientation to focus on departmental and system-wide func-tional and core process improvement. However, the strategy included little or no integration ofthe leadership, functions and processes. The system also spent a lot of time and money engaging aleadership consultant focusing on the desired skill set of its CEO, rather than on actually creatingthe reconstituted organization.There is a disconnect between the system’s stated objective of “partnering with physicians foralignment across the system,” and lack of attention to consolidating the operations of its largestphysician enterprise. This suggests that the system’s culture does not fully support its strategies. Goal #2 The second goal was to position the Foundation to play the key role in devel- Using the oping and implementing clinical integration system-wide.Foundation to Observation drive clinical Similar to our initial observations about Goal #1, we viewed the strategy of de- ploying the Foundation across all clinic and hospital processes as suggesting the integration organization is at least a market adaptor or enactor. The system has othersystem-wide is “virtual” physician enterprises that play roles varying in degree across the sys- tem. Additionally, the system continues to acquire primary and specialty physi-not supported cian practices. Frequently, the system CEO places these organizations under by culture the Foundation to manage. The system has not held substantive discussions with the Foundation about the tactics required to deploy it as the clinical inte- grator across all hospitals and physician enterprises.FindingsPositioning the Foundation to play the key role in developing and implementing clinical integrationsystem-wide is a noble and lofty aspiration. The system’s lack of commitment to implementationof the strategy suggests that, this too, is a copycat strategy. Once additional physicians are ac-quired, the responsibility for their management is shifted to the Foundation without a view to-wards how to use them to assist in system-wide clinical integration. There has not been consoli-dation of the Foundation and other “virtual” physician enterprises. Rather than being complemen-tary, their roles and functions are conflictual. Finally, the fact that substantive discussions have notbeen held to formalize how the Foundation will be the system-wide clinical integrator suggests astrong disconnect between culture and strategies.
Page 15The system-wide strategies do not conform to its culture. This is often thecase, especially with market adaptors who employ copycat strategies. More-over, this is frequently the case with hospitals and health systems that acquirephysician organizations. The system and physicians have different objectives. In System mustthis case, at the macro level, it appears that both are on the same page. How-ever, it is easier to rally around a concept such as “clinical integration,” or change its“ACO” than to actually meticulously describe and agree upon mutual goals and culture or putobjectives, especially with copycat strategies in turbulent environments. In-stead of ensuring its strategies match culture, this organization spent a rela- strategies andtively inordinate amount of time on identifying and describing desired leader- leadership atship characteristics and skill set of the Foundation CEO. Again, this is consis-tent with organizations employing copycat strategies. Unless the culture em- risk of failurepowers leadership to execute transactional or transformational tactics to im-prove departmental and enterprise-wide process improvement, achievement ofclinical integration and ACO strategies will partially or fully fail expectation.
Joseph Mack & Associates Joseph Mack & Associates specializes in health care strategy, mergers and acquisitions, physician operations, and creation of risk bearing and accountable care organizations. Our expertise is in strategic planning, finance, change management, operations, process improvement, managed care, risk management and business intelligence within highly competitive market places. P.O. Box 23 Joseph Mack has served in executive roles at hospitals, medical groups, the Dana Point, CA 92629 second largest insurance brokerage and employee benefits consulting company in the nation, the management consulting practices of two Big 5 accounting Phone: 949-481-0602 firms, as well as the nation’s preeminent medical group trade association. This Mobile: 949-697-9476 seasoning enables Mr. Mack to take a hands-on, results oriented approach E-mail: towards creating and reorganizing physician, hospital and health systems intoJoseph.Mack@jmahealthcare.com integrated collaborative provider organizations with aligned strategic, financial, operational and cultural objectives. Integrated Delivery Systems Qualifications and Experience Worked with MemorialCare Medical Foundation within MemorialCare Health System to integrate leadership and operations of the former Bristolwww.jmahealthcare.com Park Medical Group and Nautilus Health Management Company/Greater Newport Physicians, and on strategies to develop and implement clinical integration system-wide. Served as financial, strategic and restructuring advisor for a free-standing medical center’s integrated delivery system initiatives, including conducting situational analyses, financial modeling, appraisals and due diligence on several potential strategies, models, corporate structures, and organizations.Clients for which we provided Evaluated and made recommendations for a hospital to create a hospital/ integrated delivery system consulting services include physician joint venture and acquire a Limited Knox-Keene HMO License (aka risk bearing organization) to increase business. MemorialCare Medical Foundation. Long Beach, CA. Directed the financial and operational due diligence for Tenet of Mullikin Geisenger Health System. Medical Centers (later MedPartners), a $367 million integrated delivery Danville, PA. Winchester Hospital. system including a hospital, physician group and IPA network throughout Winchester, MA the State of California that was over 90% capitated representing in excess of Good Samaritan Hospital. 300,000 commercial and senior HMO members. Cincinnati, OH Catholic Healthcare West. San Created first Limited License Knox-Keene HMO organization in the State of Francisco, CA California for Mullikin Medical Centers, calculating the organization’s Sharp Health System, San Diego, CA tangible net equity. Projections were accurate through the first eight St. Joseph Health System. quarters of operations. Orange, CA Sutter Health System, Created process adopted firm wide within Ernst & Young that used Sacramento, CA organizational change management techniques to overcome resistance to UniHealth Burbank, CA change, and to create or reorganize integrated delivery systems. Wrote the strategic/operational plan for Catholic Healthcare Wests Physician strategy, which included a medical foundation, IPAs, MSOs, and a decentralized local involvement of hospitals in each region.