The Turnaround: From Hire to H.I.T.T.

While doing medical and health system consultations and turnarounds in Seattle, Washington; Johnson City, Tennessee; Berkeley/Oakland, California; and Abu Dhabi, United Arab Emirates; in addition to hard experience during my maternal-fetal medical career, I have learned many lessons.

In an effort to put the art of the turnaround in some semblance of order, let me first say there is no single true path — just as enlightenment rarely comes in a linear fashion. Upon reflection, however, there are some consistent issues, challenges and solutions.

Some readers will face these, too, and can agree with, or challenge, or perhaps use my approaches and conclusions to achieve their own goals.

Challenges in Turnarounds

To win acceptance as a turnaround expert, acquire broad-based experience that goes beyond a few hospital committees. Involve yourself with hospital quality assurance committees, department chair positions and practice leadership, and work on local medical society and state legislative endeavors. If possible, gain Joint Commission experience for a hospital or department. These types of experiences all develop know-how. It becomes easier to deal with hospital administrators, physician and nursing leaders, and major support staff as they seek your advice in an environment of personnel, contracting and financial stresses.

You need to be able to tolerate multiple personalities and inputs, appreciate teamwork, reward jobs well done and remain calm under stress. You must be able to untangle priorities. Developing an understanding of quality assurance processes, financial statements, insurance contracting and personnel issues is necessary.

Develop assurance in your decision-making, along with flexibility. You will be lonely, challenged and often uncertain throughout any turnaround process. Consider taking a Myers-Briggs personality assessment for individual insight, enhanced self-understanding, and appreciation of the types of personalities that create issues for you.

This type of work stresses relationships, so discuss with your spouse or partner whether they want to accompany you or can cope with intermittent separation. (Typically, you’ll return home every two to three weeks for a long weekend). Minimize home stress by frequent communication.

Before you accept a turnaround opportunity, consider:

• You might need to accomplish change without consensus.

• Some of the people you work with will be on your side early, some later, and some will resist or obstruct.

• It will be stressful.

• You must be flexible and able to multitask.

• Any travel requiring flight changes costs time away from home.

The Initial Engagement

The journey typically starts with a call from the executive search company you work with, to consider doing a turnaround project (or practice improvement, department enhancement or financial improvement). Be enthusiastic, and enjoy the challenge, the travel and the new system environment.

Prepare well for your initial interview. Have a list of discussion points ready after you have reviewed the job description (see Table 1). Use Google, LinkedIn or other research tools to get maximum information about the system and the management team. Check out the locations where you might be working, living, dining or doing whatever else interests you.

Initial conversations should be two-way interviews. Listen carefully to the description of your employers’ needs. Discuss your requirements, then review the needs again. Repeating often identifies initial issues not covered or not well-understood. After you and the employer agree on the well-understood, you will undergo background checks.

Some caveats as you begin:

• Reporting to more than one person makes change exceedingly difficult. Turnarounds require multiple, simultaneous, nonsequential decisions and sometimes very rapid actions. It’s hard to do this by committee.

• Travel access to the site must be reasonable.

• The duration of the contract must allow success but not be a longer term than you are willing to commit.

• Avoid acquiring hire/fire capability. It places the staff in a fearful position.

• You might need to submit interval reports to the executive search firm that connected you to the job. This extra reporting requires extra time, but allows you to refine your goals and strategies with feedback from experienced managers.

• You should report directly to the CEO or top manager.

The Initial Meetings

The first day’s reception at the job site will alert you to the level of coordination and management support you can expect. Befriend the CEO’s support staff to obtain better background of, and easy access to, the CEO, then get ready to meet with your supervisor.

Your meetings should outline the issues and complexity of each challenge. Discuss critically the financial issues and resources as well as anticipated personnel problems and possible changes. Have the CEO identify the key players and make your initial interview schedule.

Start by meeting all key executives, interlocked with some of the critical support staff. The meetings (not interviews) have a critical function — to identify your coworkers’ perception of the issues and their level of importance. Create a synopsis after each meeting, and use these notes to identify who really understands the major issues and who can help in the turnaround. The meetings should take less than two weeks and will identify possible team members (see Table 2).

Especially if dealing with a multiple-location turnaround, consider using the method of learning by wandering around. Fill gaps in your interviews by walking around to get the lay of the offices, hospitals, clinics, etc. Notice the morale and capabilities of the personnel involved. Go in at nights unexpectedly if you are dealing with 24-hour operations. Get to know the key administrative staff and give them your cellphone number. Go in the back rooms and meet your information technology and other support people. You will gain surprising amounts of information and as you talk about the goals of the turnaround, resistance declines, and cooperation begins.

You will not persuade everyone of your views for success — adjust on the fly and make corrections, but do not change your course. It is critical for everyone to understand your consultant function — that you do not hire, fire or pay their salaries, but you do advise the administrative team with new insights and help develop a change plan. You will usually lead and implement the changes with your key team members.

Your evenings often will be filled with reflecting on all this input. Make lists of people to contact the next day. Note those who do not return calls promptly — they often become an issue. If necessary, ask the CEO to send a memo to all staff that a call from you is a first priority. The speed of response increases dramatically.

Early during the initial meetings with leadership, schedule an administrative staff kickoff meeting by the end of the second week. This meeting requires that you have a rapid grasp of the issues, prioritize them and present them in a clear fashion.

• Introduce yourself and your background briefly. Emphasize that the current challenges are nothing new to you. Describe openly why you were hired. Use humor to lighten things up. Review your understanding of their current situation and outline where the current leadership sees solutions to the problems.

• Consider a short PowerPoint presentation with time for questions — all solutions will not be evident but the directions of change start to crystallize. Emphasize that you can create change only by analysis of the data you are given, and then use teamwork, persuasiveness and personal leadership to implement.

• Describe your style of operation — weekly meetings, rapid goals, division of responsibilities, a high-intensity turnaround team, or HITT approach, and accountabilities.

• Emphasize that wasted time is a hurdle and not in their system’s interest. Focus everyone on an imperative — it is almost impossible to do a turnaround until the financials are in reasonable order: “No money, no health mission.”

• Continue with your approach to finding solutions. You are not expected to be omniscient, but your presentation sets the tone. Be dynamic. Show that you are adept at rapid assimilation of facts and figures. Establish your need to make initial recommendations even with incomplete data.

• Outline high-priority items that need to be addressed. Emphasize that you are flexible as the facts change but not indecisive.

• Dress well, even in a casual work environment. You are the outsider and will be judged on many levels including appearance, posture, civility and neutrality.

• Meetings should start on time and end on time to create an “on time, every time” environment. Do not let anyone, especially physicians, show up late to enhance their self-importance. Take any offender aside and tell them if they would prefer not to have personal input, they need not attend. In the initial stages of rapid system change, few players wish to be excluded.

• Limit full staff meetings to provide essential updates and future goal-planning and implementation. Usually, only the HITT team and your CEO meetings need to occur weekly.

Using the HITT Approach

HITT originated during a turnaround of an internal medicine practice in an independent practice association model. There were multiple stresses including amalgamation of private practices, financial unsustainability, dissatisfaction with management, plus personnel and billing issues. The IPA management had internal as well as external employees with conflicting agendas.

The acronym states the reason for existence. Team members should be identified during your initial interviews and then proposed to the CEO, who can identify other people who can best help accomplish rapid change. Call them individually to invite them to the team and emphasize the importance of their input and capabilities in this critical endeavor (see Table 3). Keep the team as small as possible (five to seven people), given the number of major issues to be resolved. The managers of finance, IT, personnel, direct operations, contract negotiations and legal system are usually part of the core. The CEO must emphasize that the HITT meetings are a priority. Set weekly meetings after accommodating (or moving) other competing meetings.

At the initial HITT meeting, outline the structure of the team, its members and set goals for the meetings. Remind everyone that time is everyone’s enemy. Often, the members already are in agreement that change must occur, want to provide input, are forthright in assessing current problems and really want leadership for change.

Get input from everyone at the start (see Table 2). As a consultant, critically review what’s discussed, prioritize the agenda items, assign tasks to the appropriate staff, and determine when goals must be reached and reports returned. This avoids unclear or even erroneous statements. One member of the team keeps track of all discussion points and formulates the next week’s to-do list. Consider circular tables or sitting in the middle at meetings — this empowers teamwork and decreases authoritarianism.

Staying on track and setting expectations is helped by pre-distributed agendas. Follow the agenda at meetings even if priorities have changed, and do not drop items until resolved. Some administrators drop items of inconvenience or exceptional difficulty when instead those often are the most important things to be addressed. Use a computer spreadsheet program with access limited to HITT members. This allows real-time input as they accomplish their weekly tasks. It also provides transparency, has multiple people looking at the status of each item, and alerts the team to items slipping behind or veering off the track.

From your private weekly agenda comes a continuous list of to-do items with expected dates of completion. These are discussed with the CEO, HITT members as appropriate, and perhaps your consulting firm leadership. Again, do not drop items until resolved.

Frequent meetings with the CEO sometimes are challenging. Insist upon weekly or biweekly face-to-face meetings — they often are underestimated by leaders living on their email network (rather than walking around to see how their system is functioning). Learn to use nonverbal clues at these meetings and use these to correct course, seek new interventions, or modify approaches (see Table 4).

Remember to use the “rest of the story” method. It is an unofficial and nontransparent report to the CEO involving very sensitive financial or personnel issues. Since you have no hire/fire capability, you need to identify problematic and sensitive issues. Though counterintuitive initially, some issues cannot be publicly discussed. An example is the need to fire a tenured professor, dealing with a malpractice problem or firing a problematic employee. It is not a subterfuge — as a consultant, it’s your job to seek rapid system improvement with clarity in a very complex environment. Frank discussion about critical changes is imperative.

It often is a requirement of your engagement to prepare reports to the search firm that placed you. Use the HITT tracking timelines and your private weekly agendas, insert them into preformatted reports and your task is easier. Discuss all major resistance you have identified and need to resolve, often with the help of the search firm’s management team. The search firm uses this report to review your work and give feedback that you are doing the work optimally. This reinforces their recommendation of you as an accomplished consultant, so they can place you again in the future. Do not understate your accomplishments.

Personnel difficulties often demand uncomfortable actions. It is almost axiomatic that you will find major personnel issues, ranging from nonproductivity to incompetence to sociopathic behaviors. Consultants know that the first few people to approach you privately at the beginning of an engagement often seek to deflect personal risk. Also, as a consultant, you should not accept gifts from anyone.

Indeed, be aware of attempts to blur the professionalism line. The rules about sexual harassment apply even if you are a consultant. Remember, advances often serve to curry your favor. For lunch and dinner meetings, invite at least two people for meals so any personal attraction between attendees is kept in check. Always meet in the presence of a neutral observer, such as a seasoned administrative assistant (who can keep notes). In general, avoid casual bar meetings or the morning coffee get-togethers — you are the neutral consultant, so do not let anyone bias your objectivity with personal entanglement.

Transitioning Out

A last important task is to discuss the transition from your presence to that of the newly modified management system and personnel. Identify whether you are expected to mentor any new personnel and for what duration. Often, this involves developing a concise job description for new leader/managers, the engagement of an executive search company, and ensuring that the HITT team transitions effectively to a less-intense maintenance role. Consider small thank-you gifts or a luncheon for all the key players and describe the great progress everyone has made. Thank all the people who participated in the turnaround personally.

Turnaround work is challenging, stressful, dynamic and insightful. Take time reflect on your impact, your errors and accomplishments, and come away knowing that you have played a small but significant part in health care improvement.