by Ron Sauder

Watchful, thoughtful, deliberate. Oh yes, and young. At an age (38) when some subspecialists might just be finishing their residencies, Andrew Agwunobi, the new CEO of Grady Health System, runs one of the largest urban public hospitals in the country. But then he's already earned his management spurs as a turnaround artist in a 20-month tenure, first as COO, then CEO of South Fulton Medical Center.

Agwunobi has packed a lot of life and experience into less than four decades. Asked about his relative youth, he smiles and quotes a TV reporter who once told him: "You know, it's not the age, it's the mileage."

Our interview takes place on a late afternoon in a dusky room. A construction crew at Grady has hit a buried power line and knocked out both the lights in Grady's administrative offices. The only light comes from a picture window behind Dr. Andy (as he prefers to be called) that overlooks Jesse Hill Jr. Drive and the Emory School of Medicine's Glenn Building. A crystal paperweight on his desk identifies him as one of the "rising stars under 40" as selected by Georgia Trend magazine.

His background is well suited to Grady's multicultural population. Children of a black doctor and white nurse, he and his siblings were a distinct minority while growing up in Strathmiglo, a small village in Scotland. "My parents wanted us to appreciate both their cultures. So I did part of my medical school in Nigeria and part in Scotland." Agwunobi also holds an MBA from Stanford and is married to an Ethiopian doctor, Elizabeth Nega, whom he met while in pediatric residency training at Howard University. "I don't set out to put myself in multicultural situations," he says. "That's just the way my life has been. I like to think of myself as somewhat colorblind in that respect. My personal mission is to take care of those who are most vulnerable in our society."

Encouraging diversity, though, does not translate into being laissez-faire as an executive. After assuming the reins at Grady, Agwunobi moved rapidly to replace the hospital's chief financial and PR officers. And in a coup that elicited astonished gasps from many quarters, he recruited Emory Hospitals' venerated and just retired CEO John Henry to be Grady's new chief operating officer. He announced a campaign of "aggressive transparency," throwing open the doors of Grady's emergency care center to TV news crews in a textbook display of PR savvy. And in a striking burst of candor, he talked openly to a large group of employees at Grady about the hospital's strengths and weaknesses. We asked him to explain a memorable phrase he used in that speech that quickly made its rounds in the hospital.

I used those terms to help employees understand that I had done my due diligence in terms of evaluating Grady. I was trying to say that Grady has some fantastic qualities. Physicians here across the board give the best care in Georgia. We have great equipment and a great facility. It's a tragedy that people outside of Grady don't always know that. But we're not perfect. We need to make sure that patients can access care here without having to jump through hoops. Customer service is not as consistent as I would like. In terms of the ugly, I am talking about perceptions, such as that this is a hospital only for the poor. We are proud of our mission to dedicate our resources to the care of the most vulnerable. However, only 35% of our revenues come from the uninsured of Fulton and DeKalb counties. Fifty percent of our revenues come from Medicaid, 15% to 20% come from Medicare, and 5% to 7% come from commercially insured patients. All these people have a choice and are not necessarily indigent or uninsured.

It's still a working vision. A full, fleshed-out vision has to be something that Emory, Morehouse, the Fulton-DeKalb Hospital Authority, and other stakeholders determine together. But the working vision is that first, we will become the provider of choice for any services we choose to provide our target population.

But first we have to know what services we want to grow. Unfortunately, when you try to be everything for everyone, your mission outstrips its funding. So if we decide to provide any service, we must become the provider of choice in that service. Medicare patients have a choice, Medicaid patients have a choice, and insured patients have a choice.

But even those who don't have a choice should be able to access the best care in Georgia. We should be striving not just to take care of indigent and uninsured patients but to give them the best care possible. The status of so-called uninsured or indigent patients changes over time. They may have no insurance today but will have insurance two years from now. They may be working poor today, earning under $11,000 and therefore qualifying for some assistance from us, but they may have better paying jobs in future. They may be entrepreneurs with new businesses but can't afford health insurance for their workers and themselves today. But three years from now it's a different story. So, it's not so much about cost cutting across the board; it's more about redirecting funds so we reinvest strategically for future success.

Second, we will become the health care employer of choice for Georgia. That ties into employee morale and retention of good workers. It ties into reducing nursing agency staff. It ties into people pulling together toward the vision. If we're not the health care employer of choice, if people don't want to be here and morale is not good, we're not going to accomplish those other pieces.

The final piece is the broad vision. Simply put, we want to become the model public health care institution in financial management, health care operations, and clinical excellence. We want to be the place that other institutions send teams to when they're trying to solve tough problems. Grady already does a lot of things very well, but I'd like us to go to the next level. We're a huge tertiary-care institution with great physicians, and very committed personnel and staff. We should be the place that everybody in the community turns to for health care or thinks about first or at least on an equal level with other hospitals in the city.

Our mission is to provide health care for the most vulnerable. But we have to choose which services best fit our mission within the constraints of our funding. If we don't make that choice, it will be made for us by the fact that we just don't have the money to fund everything. That's why the physicians from Emory and Morehouse need to look together at what services we currently provide, whether we should be providing all of those services, and what else we want or don't want or are not able to provide.

Yes. I've been here for just a few months, trying to get my arms around things. At the same time, I'm putting a team together to help me do what I need to do going forward. Soon I'm going to be sitting with the medical schools, so together we can plan our strategy.

Emory, Morehouse, and Grady are joined at the hip and no one piece of that group can make all the decisions, especially when it comes to clinical care and services. I'm a physician myself. I have great respect for the work and commitment of the physicians here. There are Emory physicians who trained here, did their residency here, and are still working here 20 years later. Likewise there are Morehouse physicans who have worked at and been committed to Grady for many years. They all need to be at the table because they've seen the history; they know what works and what doesn't work. I'm going to rely on Emory and Morehouse for their expertise in trying to sift through our services to determine where to invest or reinvest strategically for success.

I'm very careful when I talk about stopping services because there are no services that don't benefit some of our patients in some way. I'm also thinking about which services to expand. I'm not able, at this point, to say whether services might be cut back.

There are a lot of opportunities for improving our finances. Some are tangible in terms of going out and seeking other funding sources, and we're working diligently in that regard. Others are more bread-and-butter administrative tactics, including short-term cost savings. For example, cutting down on the agency staff usage (for nurses).

We have great opportunity in revenue-generating initiatives, mainly tightening the revenue cycle -- basically the time the patient hits the door to the time that we collect on the back end. We're looking at everything -- from making sure that we're appropriately determining eligibility for services to streamlining our financial counseling. I'm optimistic that we can greatly decrease the deficit. Whether we can completely eliminate it is something that I haven't yet determined.

Our new chief financial officer has 20 years' experience in the private for-profit hospital industry and brings a different viewpoint to all aspects of our financial management that will help greatly to capitalize on some of these opportunities.

No. Grady will overcome the financial challenges we face. It will take initiatives on many fronts -- cost savings, revenue generation, looking for additional revenue sources, streamlining our operations, looking at our mission, and making sure that we're funding what we're supposed to be funding. But I absolutely believe we'll be able to set Grady on the right track for the next 20 to 30 years.

Yes. The foundation is going to have a huge role in Grady's future. I work almost weekly with executive director John Robitscher and the foundation board members to explore fundraising opportunities and generate more philanthropic dollars for the institution.

I'm satisfied that Emory and Morehouse are 100% behind helping Grady get on the right track. With that level of commitment from their leadership to work together, there are few obstacles that we can't overcome. So rather than talking about details of a contract, I'm more interested in the willingness of all parties to do whatever is necessary to make sure that we can go forward.

You're talking about cash flow. Improving the financial management here and looking at our mission versus its funding will positively impact all areas of our financials -- whether vendor payments or payments to Emory and Morehouse, whatever. It can only be good for everybody if our finances work properly.

I feel great optimism. Not only have Fulton and DeKalb counties approved our bond refinancing, but all six Fulton County commissioners voted in favor of Grady keeping the bond refinancing savings. Every commissioner understands the value of Grady. Some may not have agreed with certain things about Grady over the past few years, but in terms of our mission and Grady's value to the community, I've felt nothing but support from the commissioners.

What I have heard from the commissioners is manage taxpayer dollars efficiently. Communicate with us. Tell us what's going on at Grady. Help us understand how these dollars are being spent. That's what this whole proactive communication campaign helps with. I'm optimistic that we're going to get a lot of great support in the future.

No. Stories are picked up and the more sensational the better. One of the first things I did when I first came here was to let all stakeholders, both internal and external, know what the financial situation truly is at Grady. It's hard to get support if people don't understand that there's a problem. And the fact that Grady has met its obligations over the years doesn't mean that there aren't financial challenges that need to be addressed. It's not so much about Grady going away; that will not happen. It's about making the public understand that we have challenges and that we're going to have to make tough decisions going forward. But that's also good for Grady. It's a positive for us not to continue to do things the way we've always done them. We want to be strong going forward, not weak.

People ask me, are you going to cut my program? I'd like to reassure the physicians out there that I am a physician myself, not simply a number cruncher. I understand Grady's value for the community. I understand the commitment and investment that physicians have here and that it's more than a contractual relationship. For some, it's their life. All decisions we make will be in that context and will involve Emory and Morehouse.

I'm not an across-the-board cost-cutting CEO who cuts costs with no regard for overall mission and vision. We'll talk about reinvesting funds, channeling funds appropriately, and improving the level of service and quality in many of the services that we have. It may sound like a conflicting vision, but in my mind it isn't. We're looking at tightening operations and redirecting funds to support whatever ultimate mission that we come up with in terms of our scope of services.