Part II: The multi-organizational ACO team-ensuring high performance

Introduction

Part two of our three-part series focuses on the “softer skills” of ACO management - how to create a high performing team, empowered to make key decisions through consensus-driven agreement. The ACO construct is inherently complex since often each partner has a different set of needs and ideal outcome goals, which at times places partners at odds with one another. However, in order for any one partner to succeed, each partner will be required to compromise on many fronts. Areas of compromise might include the insurance partner reducing a redundant set of services, or the hospital partner sharing data previously considered confidential, or the physician practice group agreeing to standardized care plans for certain patient populations. Create high functioning partnerships with organizations that have varying agendas is the question we tackle in this section.

The Relationships

Every organization necessarily has their own culture which has been forged over time. Everyday habits and values reinforce the working norms, creating what we call “culture.” For example, each organization has a different mechanism for presenting bad news to the boss, standards regarding the quality of work and for making decisions. In an ACO with four or more partners, each brings their own norms and values. In newly formed ACO partnerships, we have witnessed the co-mingling of cultures and values as evidenced by different decision making processes, increasing tension and ill-will when it comes time to agree to standards, measures and outcomes. A low performing ACO team translates to a low performing ACO, missing contracted goals and not serving the membership.

Organizational culture rears its head in ACO partnerships when those assigned to be “at the table” are more senior administrators or clinicians, who routinely make new rules and are the final arbiter of decisions and disagreements. But in this context, seniority does not drive collaboration. This presents a challenge as these individuals must wear two hats- they maintain a leadership stance within their organization but for the ACO partnership, they must occupy a collaborative position and at times be a follower and not a leader. And we know that often within a group of leaders, one or more often acts as a “lone wolf,” where the values expressed are not partnership and collaboration.

So in a framework where collaboration, partnership and shared decision making must rule the work, how is this framework established? How do the individuals develop the skill to be able to be a follower, open to compromise, while being a leader within their organization? Avoid falling victim to an overly assertive individual who dominates the agenda and set the ACO off course and then off target.

Recommendations

The answer is to consider the socio-adaptive nature of the group, which is the ability to work with and through others. Adaptive Change broadly refers to the everyday skills needed to deal with the demands of daily living and daily functioning. For our purposes, we extend the definition to include how to work with and through others in a unified team, developing clear and outcome-oriented communications, and trust within the group. The result is the successful promotion of disruptive collaboration in order to accomplish the requirements of the ACO partnership. When these socioadaptive skills are not deliberately built into the ACO “team design,” teams will shield important data and make decisions independent from the other partners, thus causing friction amongst the entire team. Additionally this lack of transparency leads to a break down in trust, thus slowing even basic decision making abilities. Failure to build socio-adaptive skills puts ACO performance at risk.

Organizations contract to form a new ACO “partnership” without acknowledging or understanding the human factors involved in creating a high performance team. Traditional teams that come together to “Form, Storm, Perform, Norm” (from Tuckman's stages of group development) typically have an inherent shared mission and shared set of values because they come from the same organization. In the ACO context, different cultures and values are required to merge, often without the explicit discussions and framing of creating a new shared set of goals and values. Jointly developing a team Charter does not address the team cohesion, functionality and dynamics. In the absence of building a high performing team, this team focuses exclusively on “task“ as a lever for change instead of working through “relationships” which is always a more powerful lever for getting things done.

We recommend that the ACO leadership team acknowledges the “new world order” in which the ACO partnership creates a shared mission for the work, rules for decision-making and for vetting information. Introduce a series of team-building exercises so the team gets to know each other, thus developing a sense of personal connection with others. We also recommend using a team-centered debriefing instrument at the end of every meeting (refer to the attached tool below: Structured Debriefing Tool). These foundational building blocks are components of adaptive change and socioadaptive requirements - trust building, creativity, transparency, disruptive collaboration, and development of team-based and professional-based “rules of conduct” in order to drive deep creativity. Additionally we recommend the ACO establish priorities to provide relative weighting to the importance of team activities and accomplishments. When an individual or organization is dominating the direction of an issue or activity, stop and re-balance the team by encouraging other voices and perspective.

Summary
How do multi-organization ACO partnership work together in a high performing team environment? And how do they merge this new identity back into their existing company/organization? Even with competing interests within ACO partnerships, agreement on various policies and protocols must be obtained from all involved. Since we know that every organization brings their own culture, expertise and processes for getting things done, we believe it is imperative that the team invests up front time to establish their own sets of norms and values. These might be hybrids from all the partners or adoption of elements from each partner. The important point here is to establish a set of organizational routines and habits that are unique to the ACO partnership and by which participants are held to those new rules and habits. No exceptions can be made for one partner without compromising the entire integrity of the whole and team members feeling that their compromise was not valued as much as another partner or they might perceive favoritism among the group.

About the Authors
Shani Trudgian is a Partner at Kenny & Company and has over 20 years consulting experience with Accenture, Deloitte and Freed Associates. As a thought leader and industry advisor, Shani has guided her clients through health reform readiness strategy, ICD-10 readiness approach, ambulatory heath care delivery refinement, business model analysis, organizational development, change leadership and in other strategic areas. Shani’s industry experience includes medical groups/IPA, hospitals, health plan (public/private), safety net clinics, department of public health, dental insurance, oral health delivery, non-profit grant-making philanthropy, and behavioral health organizations. You can contact Shani at This email address is being protected from spambots. You need JavaScript enabled to view it..

Over the last 30 years Julie Kliger has been measurably improving outcomes in hospitals and health systems. She has done this by applying Performance Improvement (PI), Change Management and Leadership Development principles into large, complex health care organizations. Ms. Kliger is a published author and her articles can be found in the Agency for Healthcare Research Quality (AHRQ), Archives of Internal Medicine (April, 2010), Joint Commissions’ Journal on Quality and Patient Safety (Dec, 2009 and Feb, 2012), Journal of Nursing Administration (March, 2010) among several other notable publications. She has been an invited speaker at numerous national conferences including, Joint Commission, National Quality Forum, University Health Consortium (UHC), RAND Corp., Stanford University, American College of Emergency Physicians (ACEP), BMJ’s International Conference, Robert Wood Johnson Foundation (RWJF), Moore Foundation, Institute for Healthcare Improvement (IHI), American Organization of Nurse Executives (AONE). Ms. Kliger completed her Master’s in Public Administration at Harvard University’s Kennedy School of Government where she focused on patient safety and error reduction policies. She holds a Bachelor’s of Science in Nursing from Columbia University in New York City and a Bachelor’s of Arts from UC Berkeley.

About Kenny & Company
Kenny & Company is an independent management consulting firm providing Strategy, Operations and Technology consulting services to our clients. Our management consulting practice, experience and insight also enable us to provide early stage venture capital investments and management consulting guidance to select startup companies, and through our philanthropic endeavors to give back to our communities.

This article was first published on www.michaelskenny.com on October 10, 2015.

The views and opinions expressed in this article are provided by Kenny & Company to provide general business information on a particular topic and do not constitute professional advice with respect to your business.

Field Guide to Effective ACO Management by Shani Trudgian, Kenny & Company is licensed under a Creative Commons Attribution-NoDerivs 3.0 United States License . Kenny & Company has licensed this work under a Creative Commons Attribution-NoDerivs 3.0 United States License.