KentuckyOne: Building Upon Cultural Legacy

July-August 2013

BY: BRIAN YANOFCHICK, M.A., M.B.A.

It is easy to see that health care in Kentucky has been through a few phases of significant reorganization over the past eight years. Bringing together Catholic, Jewish and state academic settings into one rich mix of cultural legacy and clinical achievement makes KentuckyOne Health, based in Louisville, Ky., a unique enterprise in all of Catholic health care.

As it is constituted today, KentuckyOne Health is the third incarnation of a partnership that dates to 2005, when Catholic Health Initiatives (CHI) and Jewish Hospital and Health Services created Jewish Hospital & St. Mary's HealthCare. Jewish Hospital and Health Services was the majority owner of the new entity, which included CHI's two Catholic hospitals in Louisville — Sts. Mary and Elizabeth and Our Lady of Peace.

In preparation for this joint venture, Carl Middleton, D.Min., CHI's vice president of theology and ethics, and Rabbi Chester B. Diamond, Jewish Hospital's staff rabbi, collaborated with the Louisville Board of Rabbis and Cantors to create two governing documents. One, the "Jewish Distinctives," outlined ways in which the Jewish heritage of Jewish Hospital would be respected and maintained, including maintaining the hospital chapel as Jewish; maintaining mezuzahs on doorways; observance of Jewish holidays and Sabbath; respect for but not observance of Christian holidays, etc. The second document, the CHI "Common Values and Ethics Statement," outlined common ground on ethical issues such as the social responsibility of health care; the nature of the patient/professional relationship; and common values related to spiritual care and end-of-life care. The document also created a mechanism for managing disputes in these areas should they arise.

With the exception of managing staff expectations regarding the observance of holidays — usually around Christmastime — few conflicts arose. In many ways, the Catholic and Jewish facilities operated in parallel with one another, with little effort made to develop one culture for the joint venture.

Meanwhile, on the eastern side of Kentucky, seven CHI-sponsored Catholic hospitals came together in 2007 to form St. Joseph Health System. The system combined two larger hospitals in Lexington and five critical access hospitals located across the eastern half of the state. A significant effort followed to integrate and streamline services within that system.

In 2009, discussions began to create KentuckyOne Health, a new partnership that would join the newly formed St. Joseph Health System with the University of Louisville Hospital, the James Graham Brown Cancer Center and the city's Jewish Hospital & St. Mary's HealthCare.

Public debate about the proposal to create KentuckyOne Health became more intense in the last half of 2011 and uncovered in the Louisville community a previously unspoken distrust of Catholic health care. The concerns were sparked specifically by questions about access to women's reproductive services through the Center for Women and Infants at the University of Louisville Hospital, but they also included some surprising concerns about Catholic facilities honoring advance directives and living wills.

Also, the Jewish community raised fears about diminishment of Jewish identity at the new entity because the balance of control would shift from Jewish Hospital and Health Services to CHI, which would become the majority owner of the new partnership.

At the end of December 2011, the governor of Kentucky informed CHI he would not approve a full merger of the University of Louisville Hospital and the James Graham Brown Cancer Center into KentuckyOne Health. In his opinion, a state asset such as the hospitals, supported with public funds, could not be assumed into ownership by a sectarian organization such as CHI.

The merger of Jewish Hospital & St. Mary's HealthCare in Louisville and St. Joseph Health System in Lexington continued as planned and became effective on Jan. 1, 2012. Soon after, the University Medical Center issued a new request for proposals to select a partner that would manage the University of Louisville Hospital and James Graham Brown Cancer Center. The newly formed KentuckyOne Health was one of the organizations that responded.

In its new proposal, KentuckyOne Health addressed some of the concerns raised by the first merger attempt: University Medical Center would maintain ownership of the hospital assets, thus avoiding the transfer of public assets issue. Meanwhile, KentuckyOne Health would enter into a joint operating agreement for the management of the facility rather than effect a full merger. However, the University Medical Center would manage and operate its Center for Women and Infants, and the university's health services for women would continue unchanged.

An important note: The archbishop of Louisville vetted the proposal before it was submitted to the University Medical Center. KentuckyOne Health received a nihil obstat from the archbishop to pursue the agreement. His action was supported by input from the National Catholic Bioethics Center, which reviewed the proposal at his request before submission. A condition of the nihil obstat is an annual review of the operations of the joint operating agreement for continued adherence to the Ethical and Religious Directives for Catholic Health Care Services (ERDs). This review will be designed and conducted by CHI and the results reported to the Archdiocese of Louisville.

In November 2012, the University Medical Center accepted KentuckyOne Health's proposal, citing these reasons:

  • Mission fit, including a commitment to maintain service to the poor and underserved
  • Financial capacity for success
  • Historic collaborative work between Jewish Hospital and the University of Louisville Hospital and the James Graham Brown Cancer Center, including several high quality clinical programs on the Jewish campus lead by university medical faculty
  • KentuckyOne Health's geographic reach that offered the potential for the university to expand its clinical program across the commonwealth of Kentucky

KENTUCKY BLUEGRASS, A STURDY MAT
The work of building KentuckyOne Health began in January 2012, and took a significant new turn a year later with the addition of the University of Louisville Hospital and James Graham Brown Cancer Center.

Our system is unique in the country for its composition, and it could blaze a trail for Catholic health care into the future as we anticipate new kinds of partnerships in the new world of health care reform.

As we blend three very different organizations into one new system, Kentucky's famous bluegrass supplies us with a good metaphor: At the root level, bluegrass produces runners that mesh with the runners of neighboring grass plants to create a thick and sturdy mat. That describes our work as we balance the need to respect the unique characteristics of our legacy health systems while we mesh cultures and vision to create one KentuckyOne Health supported by a strong medical, clinical and administrative staff that benefits from leading practices across the system.

Any guru of organizational development will attest to this: Unless the leadership of an organization intentionally shapes its culture, the culture will develop of its own accord and shape the organization. Organizational culture creates the capacity for wild success, mild success or no success. Ruth Brinkley, KentuckyOne Health's CEO, has chosen the goal of wild success, and she has championed consistent and sustained efforts to define and shape our preferred culture that will position the system for leadership in the state.

The Human Resources Department has taken the lead on this effort, with significant collaboration with mission. We engaged the expertise of the Huntington Beach, Calif., consultancy Senn Delaney, which specializes in transforming corporate culture. The process began with making cultural assessments across the system. Among the important insights gained was evidence of the stress produced among employees by weathering several phases of mergers.

The assessments also affirmed there are commonly held values across the KentuckyOne Healthorganization. For example, the Jewish Hospital employees spoke of excellence, innovation and service to the community as guiding factors for their work. St. Joseph's employees spoke of quality, compassion and excellence. University of Louisville Hospital employees saw excellence, innovation and patient- and family-centered care as a focus of their work.

The specific words reflect separate organizations' histories and cultures, but the values they express show significant congruence. With this important information in hand, we have been engaged in a series of events with leaders at every level of KentuckyOne Health to focus on identifyingpersonal assumptions, leadership styles and methods that may support or hinder a healthy culture. Over the course of the next year, a "train the trainer" model will help us eventually engage all employees in the same process. There is a firm and long-term commitment to doing so.

These sessions not only teach important content. They also bring together employees from all parts of the organization — many for the first time — and foster the creation of personal networks that will be the basis for support and collaboration going forward. We are committed to maintaining opportunities for this networking so that relationships continue to grow and leading practices in care are shared.

IDENTITY, VISION, VALUES
In tandem with this culture work, we have been developing KentuckyOne Health's new mission, vision and values statements. In the fall of 2012, a small group of employees convened to draft initial statements that formed the basis for a series of conversations in focus groups and in online surveys that offer our employees a chance to describe the connection between their personal values and those held by the organization.

The KentuckyOne Health board engaged in this process as well, and it was in the context of these discussions that the board engaged itself in much-needed work to transform from a group representing legacy constituencies to a unified board that embraces its broader responsibility to the larger system.

One of our board members pointed out that to be something new, we had to do something new. In that spirit, the board has approved a new document that states our identity, purpose and future — a break from the traditional statements expressed in terms of mission, vision and values. We are now engaged in a rollout process that also supports our culture-shaping efforts as we invite employees to reflect on how our new statement of purpose finds resonance in their own work.

To help in its own formation, the board called upon Richard Chait, Ph.D., co-author of Governance as Leadership — a book familiar to many in Catholic health care. The board has allowed itself to be challenged and shaped by his very candid reflections on their work style. They see the work beginning to pay off in more engaging meetings and participation with system leadership in some important initiatives.

CHALLENGES, SENSITIVITIES
In the work of creating a new organization, there are certain intangibles that the data from culture surveys cannot express. Recognizing and addressing them requires leadership to exercise a high degree of emotional intelligence. In the case of KentuckyOne Health, the amount of change brought on since 2005 by the series of reorganizations has certainly created feelings of uncertainty among staff. Added to this is their realistic expectation of more change on the horizon due to health care reform. It becomes difficult to find any point of respite from the stress.

During visits to our facilities, I heard openness to this "new thing" that was being shaped. Many leaders expressed a hunger to get on with it. At the same time, I heard evidence at the Catholic sites of a sense of loss, rooted in the fear that they would no longer be able to express Catholic identity in the same way as in the past. Some say they have felt pressured to downplay Catholic identity in order to avoid offending the other-than-Catholic partners. Interestingly, those who expressed this sense of pressure could not name a specific source — they were acting on perceptions, and perhaps they were picking up on unintended messages from leadership.

We have begun to address this by affirming the Catholic practice of reflections and prayers on the Catholic campuses and by continuing accountability for the guiding principles of the ERDs. One hospital leader made it a point during this past Christmas season to affirm the Christian roots of the season with a crèche display that had been long absent.

Even more complex is the sense of change and loss on the Jewish Hospital campus. From the time of its foundation, the hospital enjoyed strong and active support from Louisville's Jewish community. Some viewed transferring the hospital's majority ownership and its management to a Catholic entity as a betrayal. Yet the hospital was experiencing significant financial challenges, and it had lost its edge in the innovative medical work for which it was rightly recognized in the 1980s and 1990s.

As a result, we face the challenge of finding new ways to re-engage the Jewish community in a sense of "ownership." We have received insights and ideas about this from a series of meetings with leading rabbis in Louisville. We have also enlisted their help to get the message to the Jewish community that we need their support. Without that important relationship, it becomes more difficult to affirm the Jewish legacy of a hospital where the vast majority of employees and leaders are not Jewish. The Jewish community will provide the breath of life that maintains the vitality of Jewish Hospital's legacy and aids us in ongoing efforts to reposition it for excellent performance in the era of health care reform.

The University of Louisville Hospital and the James Graham Brown Cancer Center are the newest members of our partnership. In focus group meetings with employees, it was clear they hold a well-deserved sense of pride in its commitment to the poor and underserved, its contribution to innovative medicine and its contribution to the future of health care through research and medical staff training. Their greatest fear is that much good work may be undone in the process of integration into KentuckyOne Health. We are paying attention to that concern. The new administrator of the university hospital is well-known to the staff, having served there for many years in other roles. This continuity will be important in the transition process.

CHANGE AND HOPE
It is clear that a lot of hard work has been done and continues to be done to make this new partnership work. The success we have experienced to date may be traced back to the reasons the University of Louisville chose KentuckyOne Health as its health care partner. We are all focused on excellent patient care and on making a significant, positive impact on the health of the larger community. That shared mission frames our efforts. It creates confidence that historically Catholic institutions may partner with others in a way that does not dilute deeply held values nor cause any loss of access to care in the community.

Success will continue to grow with dedicated leadership that sees its work as art as well as science. Seeing our work in this way allows us to focus on day-to-day management challenges along with attention to the sensitivities of change management. It also allows us to be patient, understanding that our integration efforts are an ongoing process — not an event defined by the signing of a contract.

The roots have begun to grow and intertwine. We look forward to the day when we can truly speak of "one KentuckyOne."

BRIAN YANOFCHICK is senior vice president of mission for KentuckyOne Health, Louisville, Ky.