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by Jon Saxton  n August 1949, an elite team of 15 firefighters known as "smokejumpers" parachuted into Mann Gulch in the Helena National Forest in Montana. Their mission: to control a forest fire started by lightning. They gathered their backpacks and equipment -- including the all-purpose "Pulaski," a combination hoe and axe, which they had been trained to keep with them at all times -- then headed down a grassy slope opposite the forested slope where the fire was raging.
The smokejumpers were moving into position to begin digging a fire line to contain the fire, when the wind changed. The blaze crossed the valley and raced toward them. They started a mad dash back up their slope, trying to outrace the deadly brush fire. But weighted down by their heavy backpacks and tools, they were running a losing race. "Drop your gear and Pulaskis," the group leader shouted. Most did and were able to run faster. Several, though, were apparently too desperate to hear or comprehend this command. As the group's plight quickly worsened, the leader had a sudden flash of insight. He started a fire ahead of himself to create a clearing of burnt space within which he and his comrades might be spared. He frantically tried to convince the others to join him, but they could not fathom this solution and did not follow his example. The only survivors were the leader and two of his crew who had dropped their packs and Pulaskis and were swift enough to outrace the fire. This tragic but true story illustrates the vital importance of leadership and innovation as well as organizational coherence and "buy-in" in the face of sometimes dire, changed circumstances. The fate of these firefighters shows how critical is the ability of leaders and innovators to catalyze reform or rejection of accepted and counterproductive practices (Pulaskis) and develop new ones (escape fires) before it's too late. These lessons also provided a motivating frame of reference for leaders of the Woodruff Health Sciences Center (WHSC), who were convened last November by Michael Johns, executive vice president for health affairs. Their goal? To examine where the center has been, where it needs to go, and what it needs to do to get there over the next five years. |
  
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 e all know that the past decade has been among the most difficult ever experienced by the health care sector. A veritable firestorm of changing conditions and expectations has swept through the health care terrain, searing many of its stakeholders and transforming its landscape.
The health care inferno was ignited by federal and private sector policies intended to slow escalating health care costs. The Congressional Balanced Budget Act of 1997 alone has stripped an estimated $110 billion out of the health care system nationwide. As it has gained force, this super-heated, cost-cutting environment has challenged insurance and payment standards, clinical practices, and professional expectations. Price competition, utilization review, precertification, heightened service expectations, demands for new investment in information technology, reduced health services reimbursements, new regulatory burdens, and consumer protection initiatives -- all of these and many others have propelled health care professionals, payers, employers, and administrators into an almost frantic scramble for survival strategies. The search is still on for a national strategy upon which to build the future success of the health care system. Over the past five years, the WHSC has weathered the firestorm, but not without significant planning, effort, and cost. When he arrived at Emory in 1996, Michael Johns adopted a proactive strategy based on extensive, center-wide strategic planning. An environmental assessment in 1997 predicted that the changes in health care pricing and reimbursement could cost Emory more than $100 million in lost revenue over five years. The assessment also identified a number of areas of weakness and opportunity where thoughtful investments could significantly enhance key programs and capabilities. The WHSC needed to reduce operational costs and organizational inefficiencies, increase productivity, and develop new revenue streams. Priority was given to improving clinical operations, bolstering targeted research capabilities with new investments in facilities and faculty recruitment, and supporting innovation in educational programs. Almost five years later, the results of these initiatives can be seen everywhere. The separate parts of what used to be called the Emory University System of Health Care have been administratively consolidated into Emory Healthcare. The hospitals have taken millions of dollars of costs out of their operations and inventory. The total of sponsored research dollars awarded to health sciences center faculty has doubled. Each of the professional schools -- medicine, nursing, and public health -- has added stellar new faculty and has revised its curriculum. Almost 1 million square feet of needed new space for research, care, and teaching have been added or are under development. This includes the new Nell Hodgson Woodruff School of Nursing building, the new Whitehead Biomedical Research Building, and the new vaccine center at the Yerkes Primate Center. Planned and in various stages of construction are the rebuilding of midtown's Emory Crawford Long Hospital, a Winship Cancer Institute building, and the rehabilitation of much existing space. At the same time, the WHSC has felt the heat of rising costs for drugs, medical devices, and supplies and severe reductions in payments for care from insurers and the government. While patient visits have risen steadily by about 4% per year and gross clinical revenues have increased modestly over the past five years, net clinical revenues and net operating income have fallen dramatically. Hospital margins averaging about 7.5% in 1996 fell to about 3% by 2000. The Emory Clinic's collection rates of more than 60% in 1996 and more than 75% in 1991 had fallen to just over 50% by fiscal year 2000. Falling revenues and margins have meant less flexibility for academic departments and clinical sections, more difficult decisions about purchasing hospital equipment and medical devices, and increasing tension over faculty compensation and clinical system contributions to academic and other university costs. (See "Through thicket and thin: Surviving change at The Emory Clinic," Momentum, spring 2000). Clinical faculty and staff, especially, have borne the burden of fighting at the front lines of the conflagration. Most have been forced to drop cherished Pulaskis, including elements of traditional faculty autonomy. Many spend more time seeing patients and less time in the lab or with students. Faculty and staff are running faster and faster just to stay in place. Meanwhile, the health care firestorm continues to close in. |
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 mory has been one of the most successful academic medical centers in the country over the past five years as it has carried out its strategic plan. Yet driving capacity and productivity will not be enough to meet unrelenting cost and revenue pressures in the future, while we strive to achieve higher levels of success in each mission area.
This is where the lessons of Mann Gulch come in. Outdated systems and practices can be improved only so much before it becomes painfully clear that they have outlived their usefulness and now hinder achieving success in a changed environment. As this becomes clearer, leadership must help us shed cumbersome and unworkable conventions and motivate the organization to develop and embrace new systems and practices. The WHSC leaders who gathered in early November came away with the clear understanding that it is time to approach both academic and clinical missions with new thinking and better tools. Refining and implementing such an agenda of innovation will not be easy and requires restructuring organizations and processes and redeploying resources and people. But this is not new to Emory. The rebuilding of Emory Crawford Long Hospital has required the review of every process and practice. Many Pulaskis were dropped in that process, and many innovations introduced. The new Crawford Long is designed to meet the heightened service expectations of patients and to incorporate the latest in operational improvements for providers and staff. (see "How to remake a hospital," Momentum, fall 2001). This same attention to systemwide review and innovation must be carried on throughout the health sciences center. As a precondition, such an agenda requires an organization suffused with a sense of shared commitment and common purpose. Without such buy-in, the attempt to lead and to catalyze change can fall short, as it did in the tragic Mann Gulch fire. Studies of that tragedy point to the group's failure to respond when things suddenly turned bad, even though leadership had found and deployed the best strategy. Whether the group lacked confidence in its leader or didn't have the necessary organizational coherence and training, it did not follow that lead. It dissolved into an every-man-for-himself strategy that proved disastrous. A key lesson taken from that tragedy is that effective organizational change, especially under stress, requires both a good strategy and an organization with the training, disposition, motivation, and confidence to follow its leaders rather than dissolve into chaos. |
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 s Emory has battled with the health care firestorm, it has become increasingly difficult to identify the unifying core purpose around which faculty and staff can rally. The three professional schools, The Emory Clinic, the hospitals, and Yerkes all share common aspirations towards excellence in the three core mission areas of teaching, research, and patient care. But from there, priorities often differ. Each has cross-cutting relationships and programs with other units, but all compete for institutional resources and for their programs and initiatives. Intra-institutional competition and stresses are less obvious and have less impact when resources are ample. But in an environment of stress and transition, all elements of the organization must be brought together around a unified purpose through which competing needs and priorities can be reconciled, and organizational cohesion fortified.
The WHSC leadership group committed itself both to developing a strategic agenda and to addressing the need for a simple but powerful vision of our common purpose. No more missions overlaid on missions. And when the group really dug down to the work of each of our units and operations, everyone came to the same conclusion. Simply put, the common purpose of the WHSC -- whether you are teaching young health professionals in training, caring for patients, or pursuing new discoveries or clinical innovations -- is Making People Healthy. The group then developed a strategic agenda, revolving around five initiative areas that Michael Johns presented to an overflow audience of faculty, staff, and students late last fall. Each will require the WHSC's sustained focus over the next five years: Financial strength. With diminishing margins and little prospect for significant increases in clinical reimbursements, the WHSC must find new ways to secure its financial strength. We must strengthen clinical financial results and eliminate inconsistencies and ambiguities in income, overhead, and other financial policies. Major fundraising initiatives will target the need to increase the endowments of our hospitals and schools and for investments in key programs and initiatives. Innovation. We must approach all of our units and operations in the same way that we approached the rebuilding of Emory Crawford Long Hospital -- from the point of view of how to drop our Pulaskis and build innovative solutions to existing and foreseeable challenges. Clinically, we must define and describe the ideal patient and provider experiences and implement them. In clinical and discovery research and in education, we must identify new approaches and support innovative people and ideas. Leadership. To sustain a legacy of excellence, we must cultivate leaders and innovators. This requires a more formal leadership development process than has ever been employed in academic health centers. We will focus on identifying and recruiting individuals with leadership potential. And the health sciences center will establish the Woodruff Leadership Institute to provide selected faculty and staff with formal orientation and training that will develop leadership skills and innovative thinking. People and the workplace. Along with creating the ideal clinical experience, each organization within the WHSC needs to define and implement the ideal work experience. We must embrace "health" as our organization's overarching theme and ambition. That includes suffusing our environment with optimism, equity, and fairness and encouraging strong and open communication. Knowledge management. Data is everywhere, and it's overwhelming. Our communication, information, and knowledge pipelines are clogged, disconnected, leaking, or lacking. Data must be not just accessible, but also useful so it can be translated into knowledge. We must develop procedures to manage the collection, packaging, and application of information and knowledge. Our complex systems of care, education, and research require technologies that communicate appropriate, timely, and accurate information and bio-information. These technologies must be safe, reliable, and dependable. A new chief information officer will be expected to create a plan to integrate the whole health sciences center together within a seamless information system. |
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 hese five initiatives represent the focus for success over the next five years. Each school and operating unit is reviewing its priorities and developing its own plans in each of these areas. Progress is already being made. A new WHSC fundraising initiative has already been approved and will move into advanced planning. The Emory Clinic is reviewing the patient experience and completely re-engineering the revenue cycle -- from patient registration all the way through to the patient's final account reconciliation. Emory Healthcare is in the advanced stages of contracting for a new, electronic medical record system that can be implemented over the next several years to provide a secure, efficient, and effective paperless patient record system.
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This spring, the leadership group is meeting again to review planning and progress in each of the five initiative areas at The Emory Clinic, the schools, and in all other operating units. All planning will be reviewed to ensure that priorities are aligned across the WHSC. Implementation will then begin in earnest to strengthen and better equip our entire organization for the common purpose of Making People Healthy. |
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Web version by Jaime Henriquez.