Tufts-NEMC: A Case of Identity Crisis

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Introduction

Perhaps one of the age-old human questions is centered on the concept of where to devote the majority of one’s time and effort. As an adaptable species, often, the first inclination of people in any endeavor is to diversify without cause or reason, attempting to be the best in every area. When such a goal indeed inevitably proves incapable of being achieved, the second response is not the logical one of choosing one area in which to excel but rather to strive for at least a minimum competency in all arenas. If it is possible to accomplish this whilst aping the tactics that apparently have made one’s competitors successful, so much the better. This failure of understanding, though it has been writ large many times throughout human history, can also be examined upon relatively small and local scales. Naturally, as the crises of the United States of America in this still-young millennium begin to revolve increasingly around healthcare, the twin follies of attempting to be all things to all people and trying to be too much like one’s fellow organizations has shown itself in terms of the organization and focus of hospitals, be they public, private, or academic in nature. In particular, Tufts-New England Medical Center (Tufts-NEMC), in the years leading up to 2006, faced a frightening onslaught of opportunities to turn away from its true purpose in serving the community, the purpose for which insurance companies would perhaps have been eager to compensate Tufts-NEMC much sooner had the teaching hospital only avoided skipping down the garden path of focusing on volume over quality. However, as the story reached its conclusion and indeed its happy ending, at least as of 2006, the hospital managed to avert a fatal encounter with the dead end which it had been pursuing for so long. This avoidance of the complete catastrophe of closing down completely is at times attributed to the leadership of Ellen Zane, who indeed showed remarkable leadership skills in the short time from taking over as Chief Executive Officer (CEO) to 2006, the point at which the current series of recommendations commence. Through an examination of that which worked and that which did not work in the years leading up to Ellen Zane’s appointment as CEO, it becomes easily apparent that, putting oneself in the position of making recommendations to Ellen Zane in 2006, the ideal path down which Tufts-NEMC must proceed prominently features an adherence to brand identity that includes Tufts-NEMC’s small size, status as a teaching hospital, and reputation as a provider of quality cutting-edge services.

1. Situation Analysis

In order to perform a sufficient analysis of the situation with which Ellen Zane found herself faced in 2006, the first task in need of completion is a thorough dissection of the forces and players which participated in the series of events leading up to that time. First, a discussion of the history of the Boston area’s medical centers and of Tufts-NEMC’s relationship to this larger framework is necessary. An extremely useful summation of this history can be found in Ingols and Brem (2006), and indeed this source provides adequate information with which to cover this topic almost entirely on its own. To begin a recap of what Ingols and Brem present, it is of note that Tufts-NEMC is one of the oldest hospitals in the United States, having been founded in 1796. This fact is important to make mention of because the very age of the hospital itself contributes to its ongoing prestige, lending an irrefutably solid aspect to the branding of the hospital. Tuft-NEMC finds itself in the current day and age sitting in a betwixt-and-between status of being very large for an academic medical center yet very small for a Boston hospital. Ingols and Brem (2006) note the hospital as being “dwarfed” by the much larger, often multiple-hospital conglomerates of Partners, CareGroup, and Caritas, raising ten million dollars in fundraising in 2005 to Partners’ two hundred million in the very same year (p. 556). However, that selfsame awkward status as large in one sense but small in another continually allowed Tufts-NEMC to provide cutting-edge services in a variety of areas, building a solid reputation for quality care that accompanied it into the 1990s. It is obvious that were Tufts-NEMC much larger, the sheer volume might have overwhelmed a focus on quality, but equally is it patent that if the hospital were any smaller, it would be able to provide advanced services only in some areas and thus lose patients with rarer conditions to other hospitals better equipped to handle that particular unusual disease. Nevertheless, despite Tufts-NEMC’s ideal position to continue providing the same excellent care for which it was known, temptations to deviate from this sound plan were on the horizon.

Veritably, it was the capitated system that first led Tufts-NEMC away from its core, and yet even this unfortunate imposition from the outside entities of health insurance companies need not have had quite the negative impact it did had Tufts-NEMC only consolidated its strength and doubled down on the things which it did best. Again borrowing heavily from Ingols and Brem (2006), it can safely be said that the capitated system’s emphasis on volume over quality was a blow to Tufts-NEMC in the 1990s (p. 546). Tufts-NEMC, it must be said, did not weather the unfortunate change as well as it might have. Rather than continue to focus on being a teaching hospital that produced excellent patient outcomes compared to its competitors, it followed suit with the other major Boston-area hospitals and attempted to become, in a sense, the “any hospital,” treating as many patients as possible. This was a mistake on multiple levels, for aside from losing its uniqueness, Tufts-NEMC simply was not and most likely never will be ideally equipped to handle large patient volumes. It is simply too small. Thus arose the temptation to form mergers, to give Tufts-NEMC additional clout in the marketplace by making it part of a larger partnership of hospitals so as to better combat and push back against the increasing demands of health-insurance companies. Yet as time would show, this temptation only led to further self-deception on the part of Tufts-NEMC.

When a hospital as revered as Tufts-NEMC considers turning its back on its long history as a non-profit academic medical center, truly it is a sign that times are dire, and yet in spite of the temptation to change, to “go with the flow,” a better alternative at the time would have been to stay the course. The proposed incorporation with Columbia/HCA could indeed have been disastrous, had it come to pass, for, as Ellen Zane puts it, such a move to join with a for-profit organization might well have led to at least eighty percent of the staff leaving (Ingols & Brem, 2006, p. 550). Staff members are the heartbeat of any organization, and if one considers seriously changing the nature of a group, such as turning a teaching hospital into a for-profit hospital, the possibility that staff might leave in large droves must also be considered. The cost of such a potential diaspora was largely ignored as Tufts-NEMC assessed the merger. Later, different problems arose when Tufts-NEMC was presented with the opportunity to join with Lifespan, a chance which it indeed did seize upon, much to the later chagrin of the management at the time. Though the 1997 deal actually accentuated Tufts-NEMC’s strengths, left out of the equation were key factors such as the role petty provincialism would later prove to play in wresting resources away from where they were needed most, be those resources funding, physicians, or even simply patients (Ingols & Brem, 2006, p. 550). Indeed, it could even be posited that part of what sealed the deal between Tufts-NEMC and Lifespan was not rational consideration but perhaps instead a motivation that stemmed from a sense of romanticism, given that the negotiations were begun when a higher-up from Lifespan found himself being treated at Tufts-NEMC and began a discussion with a doctor there. What could be more of a fairytale ending than a hospital finding its way back to security in healthcare finances through treating an executive member of their future partner organization while he was ill? Unfortunately, such tendencies to want to be rescued through a minor miracle ultimately only sealed Tufts-NEMC into its tomb a little more firmly when all the incompatibilities between Tufts-NEMC and Lifespan revealed themselves over the fullness of time. Then, in 2004, enter Ellen Zane, the real savior Tufts-NEMC needed.

Ellen Zane contained just the right mix of experience, hopefulness, and willingness to meet with people from all walks of life to bring Tufts-NEMC back into the light. Her motivation for taking the position as CEO came, she says, not from a place of wanting to make more money or even just keep busy, but rather out of a sincere belief in Tufts-NEMC and what she later refers to tangentially as a “fire in the belly” to keep the historic teaching hospital from closing (Ingols & Brem, 2006, p. 555). That is to say, it was, in one sense, Tufts-NEMC’s image as something worth preserving, something unique out in the marketplace of so many hospitals in the Boston area, that motivated Ellen Zane to come on board. Indeed, then, it can be said that even before Ellen Zane stepped on board, Tufts-NEMC was gaining benefits from its high status without consciously striving to do so and in spite of the losses its reputation had taken in recent years due to the inevitable hits associated with being near to closing down. Once there, Ellen Zane spent a great deal of effort raising the Tufts-NEMC name back up into prominence, getting involved in the political side of things on Beacon Hill, speaking to doctors who had left to go to other hospitals when they would have preferred to stay at Tufts-NEMC, and identifying eight areas in which Tufts-NEMC would not just provide adequate care, but excel (Ingols & Brem, 2006, p. 556). While some of her efforts were focused on eliminating Tufts-NEMC’s more negative aspects—e.g. a length of stay one and a half days above the average for competing hospitals—it is obvious that the bulk of her work was in making Tufts-NEMC appear more unique and prestigious, from ensuring the name was never left off the logos again to instigating “town meetings” that got all the staff on board with feeling they were part of a cohesive group (Ingols & Brem, 2006, p. 557). Going forward from 2006, the point at which the story leaves off in Ingols and Brem (2006), it is just this sort of brand-name and team-spirit building that Ellen Zane must continue to use to ensure Tufts-NEMC is viewed as a single, discrete entity. The old truth that communications theory teaches holds even for hospitals: People connect better to a person than to an idea. By making Tufts-NEMC a pseudo-person, a discrete organism with unique functions and a certain cohesiveness or definition of boundaries and limitations, Ellen Zane had by 2006 transformed it from something hard to hold in the mind to an entity people could readily understand.

2. Assumptions and Missing Information

Though in truth the information thus far presented contains much that is accurate in a streamlined form, to get a fuller picture, it will be necessary to go outside the case study analysis presented in textbook form by Ingols and Brem in 2006. Whereas that case study does indeed note an emphasis placed on honesty, as instigated by Ellen Zane beginning in 2004, it is interesting to note that outside sources do indeed corroborate the assumption that Ellen Zane’s personal honesty led to greater organizational honesty. In Diamond (2005), for example, it is a representative from Tufts-NEMC who speaks on such issues: “Judy Levy, RN, the director of quality improvement and clinical services operations at Tufts . . . says that peer-reviewed discussions between health plans and hospitals . . . give hospitals a chance to openly discuss adverse outcomes” (p. 35). Here, the idea of “openly discuss[ing] adverse outcomes” ties directly into the culture of openness and honesty that Ellen Zane had been cultivating since arriving in 2004. Still, it is perhaps invalid to assume that Ellen Zane alone was responsible for the change; a topic on which little research appears to have been done, and thus little corroborating evidence created, is the Tufts-NEMC culture in the 1990s and early 2000s. This could be considered an area of missing data, as Ingols and Brem’s 2006 case study mostly focuses on merger and other decisions made during that period, only switching to the “softer” approach of examining corporate organizational norms once Ellen Zane has entered the picture. It can be assumed from this absence, which mirrors an absence in the literature, that not much at all is known about Tufts-NEMC’s culture prior to 2004. Perhaps this could even be viewed as embedded sexism in the literature, for it seems all too often CEOs who happen to be women are lauded for bringing such qualities as “caring” or “increased communication” to an organization, versus words like “plans” and “decisions” used to refer to COO Ed Schottland’s earlier work at Tufts-NEMC (Ingols & Brem, 2006, p. 550). Clearly, more research is needed to determine just what the differing emphases of men and women leaders in organizations are, if any. Only through such investigation can the role Ellen Zane played in creating Tufts-NEMC’s new culture of honesty be more thoroughly examined. Nevertheless, this is not the only point on which the suggestion of assumptions and missing data may be valid.

Another area in which the Ingols and Brem 2006 report lacks sufficient detail is in the relationship between the Boston area hospitals and hospitals in the United States of America as a whole. Indeed, only one brief reference to “industry standards” is made amongst all the tables of the case study, with the seven other graphs, tables, or diagrams all referring to Tufts-NEMC uniquely, the Boston area alone, or at the most, Massachusetts as a whole. Though this topic is not the focus, another article sheds light on this topic, as summarized in the abstract, “[The researcher] first examines recent economic changes in the US hospital industry, which have resulted in a record number of mergers like the Dekalb and Gwinnett Medical Center, closures, and conversions” (Savage, 2004, p. 547). Indeed, this brief account is quite an accurate portrayal of this portion of the content of the study, and interestingly, what is shown is that Tufts-NEMC in particular, and the Boston-area medical centers in general, were not at all unique in the troubles they faced throughout the 1990s and early 2000s. However, without this evidence, it would indeed have been very difficult to place the Boston-area hospitals in relationship with the rest of the country, particularly considering that Massachusetts proved to be such a unique healthcare environment that the climate later gave birth to the well-known semi-socialized health insurance system still functioning in one form in Massachusetts today, of which most readers will undoubtedly have heard at least by the more colloquial name of “RomneyCare” (Diamond, 2008, p. 46). Returning to 2006, it does appear that in spite of queries to the contrary, the challenges faced by Tufts-NEMC were not vastly different from the norm among medical centers in the United States of America. Thus, though more data could certainly be provided on this topic, this no longer needs to be considered an area of missing data or of overly troublesome assumptions.

3. Problem Definition

Now that the data leading up to 2006 have been presented and issues with said data examined, it is obvious to see that the problem faced by Ellen Zane as CEO at this time was to continue propelling Tufts-NEMC forward on its upward trajectory in spite of future obstacles that might arise. Indeed, though much success had been wrought up to this time, there was always a chance it could all be undone with one deal falling through, as happened with the Harvard Pilgrim situation in 1995 (Ingols & Brem, 2006, p. 549). However, though of course disaster could strike at any time, the main challenge going forward is primarily one of forward momentum. How will Ellen Zane continue to ignite in her staff the same sense of simultaneous urgency and hopefulness that she did at the beginning? What will prevent top physicians from losing interest as the challenge appears to be solved and perhaps being seduced away by other hospitals? How will Ellen Zane begin to shift responsibility off of her own shoulders so that should she decide to leave, others can pick up where she left off? These are all valid questions.

4. Development of Alternatives

One of the key troubling factors is the lack of perceived alternatives to Ellen Zane’s leadership. If no one in the hospital feels carrying on without her will be possible, not only is there a great risk if something did cause her to leave, but this would also be evidence that she has not done an adequate job spreading responsibility around. Though colleagues do seem to speak of her as a great collaborator, at the same time, there seems to be a conflation of Ellen Zane with Tufts-NEMC, when in reality, one is not synonymous with the other. Truthfully, there are no alternatives to ensuring Tufts-NEMC can function without her; sooner or later, they will need to do so. The only alternative, waiting to see what happens, is a poor one.

5. Evaluation of Alternatives and Recommendations to Management

Ellen Zane must begin to delegate greater responsibility to other senior officers at Tufts-NEMC. This might best be done by deliberately taking a long vacation or a sabbatical of perhaps six months, during which staff are forced to handle problems on their own. Upon her return, Ellen Zane would then be able to help evaluate what went wrong and how to prevent such failures in the future. This can be seen as a “dry run,” or else as a simulation of the reality of Ellen Zane’s actually leaving. After doing so much work to build up Tufts-NEMC’s identity as a brand, it would be a shame if Ellen Zane were to let it all fall by the wayside because people could not mentally separate the hospital from the woman who ran it.

Conclusion

Tufts-NEMC can continue to hold its position, so recently regained, as a teaching hospital that pioneers cutting-edge techniques. However, as with any company building an identity, though individuals with strong personalities can help begin the process, ultimately, the focus must shift from being on a person to being on the organization. Though such a task is difficult, this has long been the challenge faced when groups of people are “rescued” by a single charismatic leader. Organizations must learn to stand on their own two feet or else risk an unending cycle of plummets into despair followed by ascent aboard the wings of a rescuer. To learn to rescue without dominating, and to learn to be rescued without becoming dependent, are the twin challenges that so many have faced throughout human history. Everyone must learn these lessons whether they arise in one’s own life or even merely in stories told about others.

References

Diamond, F. (2005). Hospitals may see plans as their new confidant. Managed Care, 14(5), 35.

Diamond, F. (2008). Delivering RomneyCare. Managed Care, 17(5), 46.

Ingols, C., & Brem, L. (2006). Ellen Zane: Leading change at Tufts-NEMC. In P. M. Ginter, W. J. Duncan, & L. E. Swayne (Eds.), Strategic management of health care organizations (6th ed.; pp. 539-568). Hoboken, NJ: Jossey-Bass.

Savage, L. (2004). Public sector unions shaping hospital privatization: The creation of Boston Medical Center. Environment and Planning, 36(3), 547-568.