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Memorandum To: Elaine Brennan, Head of Montefiore Hospital From: Wagner Consulting Analyst Date: April 17, 2019 Re: Promoting Care Center Model and Balanced Scorecard to Improve Montefiore’s Performance Executive Summary Known for its commitment to social service and scientific progress, Montefiore began suffering from management and financial challenges in the mid-1990s. Firstly, there was misalignment between what Montefiore said their mission was – focusing on patient care – and what clinicians wanted to focus on, which was academic research and teaching. Secondly, decreased revenues from generous payers, increasing presence of price-sensitive payers, and fierce competition began to compromise Montefiore’s financial and market position. While you have made great strides in developing care centers and implementing the balanced scorecard approach, there is opportunity for growth and improvement by: a) addressing clinician challenges by involving them in decision-making and b) working more closely with internal telecommunications team to disseminate information about the balanced scorecard and team restructure to middle management and clinicians. Background Montefiore has experienced much change since its founding in the late nineteenth century. In the mid 1950s, Montefiore formed a partnership with the then-newly formed Albert Einstein College of Medicine by agreeing to operate Einstein’s patient-care facility. To address management and financial challenges, you have developed two action items: moving to a divisional structure using a care center model and using the balanced scorecard to set broad and local strategy. However, challenges remain with clinician buy-in for these two ideas. For the former, there is concern around smaller departments not being assigned to a care center and about certain service lines being too siloed. For the latter, there have been challenges in creating opportunities for clinician leadership at the broad and local levels to inform each other’s balanced scorecard priorities. Recommendations Addressing Clinician Challenges by Involving Them in Decision-Making In implementing and executing against the care center model, there has been opportunity to empower nursing staff and understand the linkages between support centers and patient care. However, there are still concerns from clinical team members about service lines being siloed and about the management of non-care center service lines. The best way to address these challenges is to directly solicit feedback from these clinicians about what they think would work best. If physicians believe that it is worthwhile to distribute the smaller service lines across one or two new care centers, then that can be an idea worth engaging. As for service lines being siloed, it would be necessary to obtain data that might support this claim. The best way to do this might be to look at employee and patient feedback, as well as quality scores among patients with complex comorbidities. The importance of the former is that employees can indicate what might be hindrances to their workflow (ex: extra steps necessary to obtain information from a different care center for the same patient), while patient feedback can help you understand where there might be efficiency gaps. Looking at quality scores will be important in understanding what the direct outcomes are of restructuring teams in this way. Being able to come back to clinicians with evidence that can support—or deny—their claims will be necessary to gain trust. Ensuring Communication about Balanced Scorecard among Clinicians and Middle Management

While the development of the balanced scorecard has been fairly coordinated and decentralized, it is missing key perspectives from clinicians and middle management. This is primarily because these populations have been treated as “consultants” or left out entirely and have not been meaningfully involved in the actual process from the beginning. The best way to get them involved is to ensure that they have access to complete information through consistent communication. For example, you have an opportunity to work with the VP Ancillary Services’s telecommunications team to ensure that clinicians and middle managers understand what the purpose of the balanced scorecard is, and, more importantly, the rationale behind its creation. For clinical leaders in particular, it needs to be made clear that while the balanced scorecard’s primary focus is on financial sustainability, there is a more mission- driven way to design the scorecard. Implementation I present these recommendations, in the order specified, to ensure that care center concerns are addressed and communications are streamlined: 1. Partnering with physician and nursing leaders – particularly those who are vocal about their concerns with the care center model—will be essential to coordinating care across service lines. As such, you should coordinate with the nursing directors and heads of the various service lines (through the patient care services structures) to collect their concerns and see what they think the best way to coordinate these service lines might be. You can set up recurring meetings to ensure that you can build a robust care center structure for these remaining service lines. It will also be important to increase coordination across care centers to ensure departments are not siloed – as such, meeting with the care center leaders and develop a robust meeting schedule with them to create a platform to speak about different patients. 2. Working alongside the Telecommunications team under the VP Ancillary Services, you will need to develop a strategic communications plan to share out information about the balanced scorecard to clinicians and middle management. At first, it will be necessary to analyze existing communication channels and learning to leverage those; however, creating a feedback mechanism will also be paramount. Conclusion Alternatively, you can continue to push through the care center structure and balanced scorecard without accounting for these dissenting or qualifying voices. This may continue to cause tension throughout Montefiore, especially during a time when your focus should be on retaining clinical talent and improving financial performance. While Montefiore is focusing on success for the future, the above recommendations will not only strengthen relationships across different departments and between different functions, it will also build trust among all levels of leadership. Ultimately, these approaches can support improved finances and re-establish Montefiore’s place as a trusted medical center in the Bronx.

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