Case Study: Ron Ventura At Mitchell Memorial Hospital

Harvard Business School Senior Lecturer Frank V. Cespedes and Boston College Adjunct Professor of Management Heide Abelli prepared this case solely as a basis for class discussion and not as an endorsement, a source of primary data, or an illustration of effective or ineffective management. Although based on real events and despite occasional references to actual companies, this case is fictitious and any resemblance to actual persons or entities is coincidental. The authors wish to thank Victor E. Pricolo, chief of general surgery, SouthCoast Health System, for his contributions to the case. Copyright © 2013 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business Publishing, Boston, MA 02163, or go to http://www.hbsp.harvard.edu. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.

F R A N K V . C E S P E D E S

H E I D E A B E L L I

 

 

Ron Ventura at Mitchell Memorial Hospital

Andy Prescott, chief of the Cardiovascular Center at Mitchell Memorial Hospital, pored over the performance-evaluation packet for the hospital’s star vascular surgeon, Ron Ventura. The evaluations, which were the result of a 360-degree performance review cycle the hospital had recently put in place, were far more critical than he had anticipated. (See Exhibit 1.) Prescott was aware that Ventura was having difficulty adjusting to Mitchell Memorial and working with other surgeons and hospital staff. Additionally, Prescott wondered whether Ventura’s actions violated Mitchell Memorial’s cultural norms.

Ventura had a national reputation as an accomplished vascular surgeon. He had improved the vascular surgery practice enormously in his short tenure at Mitchell Memorial and generated much new case flow for the hospital. Ventura was also——as the evaluation packet made clear——sharp- tongued, impatient, and abrasive. Prescott knew that the Cardiovascular Center needed team players but he also had a responsibility to improve the performance of the vascular surgery practice, and Ventura was critical to that effort. Now Ventura’s contract was up for renewal and Prescott was responsible for making the decision regarding Ventura’s contract. Although he had recruited Ventura and given him strong support, other surgeons were now considering leaving the hospital and Prescott was getting complaints from the nursing staff and from the residency programs: many pointed to Ventura’s behavior as the cause.

Mitchell Memorial Hospital

Mitchell Memorial Hospital, founded in 1932, was a 750-bed regional academic medical center in Ohio. The hospital offered clinical services including primary care and many medical and surgical sub-specialties. Revenues were concentrated in three designated centers of excellence: cancer, cardiovascular disease, and orthopedics. Mitchell was also in the midst of an organizational renewal. Under the leadership of Jane McAdams, MD, the hospital’s CEO since 2008, Mitchell had made tremendous strides in establishing a culture more focused on teamwork and collaboration among physicians and staff as part of its overall effort to increase emphasis on quality outcomes for patients.

 

9-913-572 J U N E 2 8 , 2 0 1 3

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

2 BRIEFCASES | HARVARD BUSINESS SCHOOL

The hospital took very seriously the Joint Commission Standard L.D.03.01.011 which stated that ‘‘safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the organization.’’ (See Exhibit 2.)

Prior to McAdams’s leadership, the hospital’s administration had not been particularly concerned about cultural issues, expectations regarding physician conduct, or the extent of collaboration among physicians, staff, and management. However, the hospital’s board of trustees recruited McAdams because she had a deep knowledge of the changing regulatory landscape in health care and, more importantly, had a clear vision for how Mitchell’s culture and care delivery strategy needed to be re- aligned to better position Mitchell in the increasingly complex, more regulated, and rapidly changing U.S. health-care environment.

McAdams refined the hospital’s mission statement to reflect her own vision:

Mitchell Memorial is a medical institution dedicated to providing the highest-quality patient care, with relentless attention to clinical excellence and patient safety. Mitchell Memorial’s people are the source of our ability to deliver on this promise. We will distinguish ourselves by creating an environment that fosters teamwork and innovation, by developing and utilizing the abilities of our physicians and staff to the fullest benefit of our patients and by treating each other and our patients with dignity and respect.

She also established a ‘‘Team Mitchell’’ physician compact that every physician was required to sign upon joining the hospital’s staff. This compact included a section on Team Collaboration. (See Exhibit 3.) Mitchell’s administration also swiftly put into place a code of conduct that defined the range of acceptable, disruptive, and inappropriate behaviors, for physicians practicing at the facility; instituted new HR policies; implemented compensation incentive plans that fostered collaboration; and recruited physicians for leadership roles who would help shape the culture and accelerate a move to Integrated Practice Units (IPUs.) In contrast to more traditional, siloed organizational approaches, IPUs sought to provide the full complement of care for a patient’s medical condition by utilizing dedicated, multidisciplinary teams. McAdams was a strong proponent of the Integrated Practice Unit model:

Patients interact with the hospital at many different points of intersection. It’s critical from a business perspective, as well as for patient outcomes, to provide a unified face to the patient and to effectively coordinate services to the patient across a disease category, but success requires teamwork and collaboration on a whole new scale.

Implementing the new vision was the responsibility of the hospital’s executive team and leaders in the clinical departments, including Prescott and his team in the Cardiovascular Center. (See organizational chart in Exhibit 4.)

The Cardiovascular Center at Mitchell Memorial Hospital

Cardiovascular disease was typically a major source of revenue for medical centers and Mitchell was no exception. Cardiovascular disease included abnormalities of the heart, its blood vessels

1 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a United States-based nonprofit organization that accredits more than 19,000 health care organizations and programs in the United States. A majority of state governments recognize Joint Commission accreditation as a condition of licensure and that it is required for receipt of Medicaid reimbursement. The mission of JCAHO is to improve health care for the public by evaluating health-care organizations and inspiring them to excel in providing safe and effective care.

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 3

(coronaries), and peripheral blood vessels. Common heart disease included coronary artery disease, valvular heart disease, heart failure, and cardiac rhythm abnormalities.

Andy Prescott was recruited to Mitchell to create a center of excellence in cardiovascular care. During his short tenure, he had successfully transformed the way cardiovascular care was delivered by creating an IPU in that area. (See Exhibit 5 for a diagram of the patient-centered IPU concept in the Cardio Center.) To this end, Prescott co-located procedure rooms and outpatient clinics for cardiology, cardiac surgery, vascular surgery, and vascular and interventional radiology. Physicians could more easily communicate because all providers in a common organizational unit and care delivery teams met formally and informally on a regular basis. Prescott believed that the IPU expedited patient care, built trust and a sense of community, and reduced internal competition among specialists in cardiovascular disease. Prescott had also established a diagnostic vascular lab in which cardiologists, cardiac surgeons, vascular surgeons, and radiologists jointly interpreted and reviewed non-invasive and more invasive diagnostic imaging tests.

Prescott had four division chiefs reporting to him: Cardiology, Cardiac Surgery, Vascular Surgery, and Vascular & Interventional Radiology. As Prescott put it, the move to an IPU was not easy. Although only vascular surgeons could perform certain procedures, there was competition among vascular surgeons, vascular and interventional radiologists, and interventional cardiologists in performing procedures such as angiograms, balloon-assisted dilatations, and stenting of arterial stenoses. Prescott elaborated:

Competition among cardiovascular specialists is intense. I’ve seen it firsthand at Mitchell over the years. Interventional radiology revolutionized vascular care and drew patients away from the surgeons. Interventional cardiologists, and then vascular surgeons, eventually realized that they needed to acquire similar vascular skills to reclaim patient access.

As chief of vascular surgery, Ventura had two vascular surgeons reporting to him. Vascular surgeons performed intricate and complex procedures on all blood vessels except coronaries. Peripheral bypass surgeries and carotid endarterectomies (surgery to clear blockages in the carotid artery) were historically the two most common surgeries performed by vascular surgeons. However, surgeons were increasingly using less invasive procedures such as angioplasties and endovascular stents to restore flow to narrowed arteries of the lower extremities. They were also doing more minimally invasive procedures to treat enlarged arteries by placing grafts within the artery rather than performing open repair procedures. This required interaction and coordination of care between vascular & interventional radiologists and vascular surgeons, and between cardiologists and cardiac surgeons regarding a patient’s situation. Depending on the disease condition, each patient had access to a team of physicians from each department in the Cardiovascular Center.

Vascular surgeons performed multiple procedures in the operating room in a single day and generally worked in teams comprised of OR surgical nurses, fellows, and residents. (See Exhibit 6 for a diagram of a typical operating team.) A teaching hospital, Mitchell trained general surgical residents and offered more advanced fellowship training in vascular surgery. The hospital also offered training programs in cardiology, interventional cardiology, radiology, and vascular and interventional radiology. The programs at Mitchell were considered outstanding by top-tier medical schools, and Mitchell could typically recruit highly accomplished medical school graduates into its training programs.

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

4 BRIEFCASES | HARVARD BUSINESS SCHOOL

Andy Prescott

Mitchell recruited Prescott, a highly regarded interventional cardiologist with eighteen years of experience at another top academic hospital, to head the Cardiovascular Center. Prescott quickly assumed a strong leadership role as director of the center.

Prescott described the context at Mitchell Memorial:

Most hospitals don’t attract business; individual physicians do. The ability to bring in new cases depends a lot on the entrepreneurial ability and reputation of the individual physician. Those hospitals sometimes turn a blind eye to certain behaviors because the pursuit of cases for the hospital and the survival of the physician in that hospital’s environment are more important. If you rock the boat internally to get in new patient cases or enhance the reputation of the hospital, nobody is going to raise a red flag and say we shouldn’t be tolerating that kind of behavior. At Mitchell, this is just not the case. Here the overall culture of the hospital and integrity of the process are incredibly important.

One of the areas where Mitchell historically had been weak was vascular surgery. Prescott had successfully built this capability in his previous position and he sought the right surgeon to build Mitchell’s reputation in that specialty.

Prescott recruited Ventura because the latter had a track record as an outstanding surgeon, strong experience in endovascular techniques that Mitchell’s surgeons lacked, and, in Prescott’s eyes, the type of energetic and entrepreneurial nature that Mitchell needed to create a stronger division:

I felt really lucky to get Ron. He trained the vascular surgeons in our group, and we started seeing the results immediately. His techniques are less invasive with fewer complications and more favorable patient outcomes. By all standard measures our performance in vascular surgery improved. Within a year we saw declines across the board in 30-day mortality rate, length of hospital stay, unplanned returns to the operating room, and other stats. Before Ron joined us, Mitchell experienced mortality rates from ruptured aneurysms at greater than 50%. That kept me up at night. Today, we no longer cross-clamp the aorta and we’ve seen the mortality rate for these patients drop to less than 40%. In our field that’s significant progress. With all the changes in health care regulation and reimbursement, outcome data like this is more critical than ever for hospitals. Ron’s leading the charge there. Any other hospital in the region, or in the U.S. for that matter, would want Ron as a vascular surgeon on staff. He’s had headhunters on his tail since the day he started here. Candidly, without Ron, we wouldn’t have a vascular surgery department worth mentioning.

Ron Ventura

Throughout his twelve years as a vascular surgeon, Ventura had established an exceptional technical reputation and was looking for the next challenge. When approached by Prescott to join Mitchell in the summer of 2011, he was initially skeptical:

I wasn’t sure I would fit into Mitchell Memorial. I’m not like the other surgeons here. They’re academic types. I don’t like the ‘‘academic surgeon’’ label. The physical challenge of being a surgeon is what really motivates me. I work hard and expect others to; and, for the patient’s sake, I’m not afraid of anyone or anything in the OR.

Ventura started college at Colorado State but dropped out after a year. He decided to go back to school at the University of Arizona. After completing his undergraduate degree in physics he went on to attend the University’s Medical School. On the advice of one of his professors he pursued a residency in surgery.

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 5

My father was a truck driver and I was the first in my family to go to college. Growing up I never thought I would become a surgeon, but I realized early on in medical school that I might have what it took to be good at it. I liked the fact that not everyone was cut out for it. So many residents who started in the surgery program dropped out. There was a certain thrill of victory when I got through each year. It was like I was part of some elite military unit that had survived to fight the next major battle.

Upon finishing his residency, Ventura pursued a fellowship in vascular surgery at a renowned heart hospital in Texas.

That was tough. The guy I worked for had been a surgeon in the Army for 15 years and it was command and control in the OR. He ordered me around like I was a buck private, but he taught me everything he knew and was the best vascular surgeon anyone could hope to learn from. I think that he was the hardest on me because he thought I had the most potential. He’s the only person in my life I ever wanted to impress and sometimes in the OR I think about him and it makes me a better surgeon.

In the intervening years Ventura established himself at a large Midwestern hospital, but he grew frustrated because he knew the incumbent chief of vascular surgery was unlikely to retire for at least a decade. Despite his reservations about Mitchell’s culture, Ron left to join Prescott as chief of vascular.

There aren’t a lot of other doctors that I look at and say ‘‘that guy can hold his own.’’ But I have deep respect for Andy. He commands an audience and I thought that, in spite of any issues I might face at Mitchell, Andy would support me, because he can cut through the red tape and focus on what matters at the end of the day. I joined Mitchell Memorial with one goal in mind: to make vascular surgery the strongest division at the Cardiovascular Center. I expected everyone else to assume the same sense of urgency I had around building out the practice. I didn’t have time to engineer consensus on the changes I needed to make.

Ventura’s style and drive started to create problems almost immediately. Prescott learned of Ventura’s issues but initially tried to defend him. Prescott argued that the surgeon just needed time to adjust to Mitchell’s culture. However, when the problems continued, Prescott grew increasingly concerned. Still, he didn’t feel he could take a heavy-handed approach:

Ron would come to my office and ask ‘‘what’s the problem?’’ and I would say, ‘‘Go and talk to this cardiologist or that nurse and smooth things over.’’ I tried to be diplomatic and give advice in an understated way. I didn’t want to confront Ron head on. No one did. I also believe that sometimes conflict can be constructive when what is best for the patient is at the heart of the debate. It’s also a difficult environment that surgeons face today. Reimbursement is going down, which puts enormous financial pressures on surgeons. There are increasing regulatory requirements and surgeons have less autonomy than they used to. There’s a sense of loss of control and frustration at the growing complexity of the health-care system. On top of that, vascular surgery is technically challenging and requires meticulous attention to detail. I wanted to cut Ron some slack. I had made the decision to hire Ron and I needed it to work out.

However, the recent evaluations made it impossible to avoid the concerns about Ventura’s interpersonal style. One highly respected surgeon at the center described him as ‘‘arrogant, overbearing, insecure, and sometimes flippant.’’

Prescott commented:

It has taken time to build the teamwork that is now a source of pride for the hospital’s staff. I won’t sacrifice the integrity and transparency of our processes for the sake of building our reputation. As the leader of this center of excellence, I want to send the right signals to the other physicians. If I tell

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

6 BRIEFCASES | HARVARD BUSINESS SCHOOL

everyone that Ron just has a ‘‘surgical personality’’ or that he expects everyone else to adopt his high standards, am I in effect telling everyone that behavior doesn’t count——and that we put caseload, ability to generate revenue for the hospital, and prestige ahead of how we treat each other?

Ventura suggested that Mitchell was focusing on the wrong things.

In the operating room, form doesn’t matter. Substance does. There’s no time for ‘‘please’’ or ‘‘thank you.’’ It’s life or death. I and others need to be 100% focused all the time on the job at hand. Would the hospital rather have the surgeon who always says the ‘‘right’’ thing to everyone using exactly the ‘‘right’’ tone or someone who might be rough around the edges but gets the job done efficiently, every time, with a good outcome for the patient and the hospital and his colleagues’ careers and reputations?

The Cardiovascular Center was second only to the Cancer Center at Mitchell in terms of revenue generation; and, in spite of decreasing reimbursement for cardiovascular procedures, the Cardiovascular Center’s revenue had grown an impressive 22% per year since Ventura had come on board. Each patient case had associated physician and hospital charges, which resulted in revenue for the Cardio Center. Ventura generated $3.2 million annually in revenue for the hospital by virtue of the sheer number of patient cases he personally handled. For example, Ventura had seen 1,122 outpatients in a single year, the greatest number of any surgeon at the center, and his volume of high- reimbursement inpatient vascular procedures was the largest. Beyond that, the cases Ron brought in had a positive halo effect on business in other medical divisions throughout the hospital, including urology, endocrinology, neurology, and others.2 Ventura tackled the toughest vascular surgical cases and physicians throughout the region increasingly referred cases involving any vascular work to the Cardiovascular Center at Mitchell because of Ventura. Some 54% of new vascular patients were now referred by non-Mitchell physicians, up from 26% just the year prior. This data showcased the power of Ventura’s reputation among referring physicians and his ability to bring wholly new patient populations into the hospital, generating new and growing revenue streams for the hospital. Ventura was a ‘‘producer.’’

Surgeon Performance Evaluation at Mitchell Memorial

Like most top-tier hospitals, Mitchell conducted peer review (when necessary) of cases involving patient complications, complaints, reported concerns, litigation risks, or evidence of failure to follow protocols and guidelines. The formal, 360-degree performance evaluation process of physicians was new to the hospital. McAdams had introduced the 360-degree process with much staff fanfare. Prescott was a strong advocate of the 360-degree review, and this was the year he had made the program mandatory across all specialties in the Cardiovascular Center.

The performance evaluation process was intended to provide developmental feedback so that physicians could continue to improve skills in teamwork, communication, and contribution to the ‘‘unified culture.’’ Evaluators were asked to comment at length on an individual’s strengths and weaknesses, providing detailed and specific answers, and submit responses using a software program the hospital had selected to aid in the management of the review process. However, there was some uncertainty among physicians regarding how output from the qualitative review process would be directly linked to change in behavior/execution on the job. One physician commented:

2 Vascular surgeons often treated conditions resulting from complications of diabetes and other chronic conditions. The halo effect referred to in the case relates to the fact that a diabetic patient who chooses to have complications of his disease surgically treated in a specific hospital might subsequently choose to have all care related to the condition delivered at that same hospital.

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 7

There was an expectation at the hospital that someone had to be a ‘‘team player’’; but there wasn’t a very specific, defined set of criteria that you could manage people toward or that you, as a professional, could manage yourself toward.

In his self-evaluation, completed while others wrote their evaluations of his performance, Ventura recognized that he needed to acquire some ‘‘patience’’ in dealing with staff members. He described wanting to do ‘‘a better job communicating across the team.’’ However, his self-evaluation was short and he emphasized his successes.

Having pored over Ventura’s evaluation packet, Prescott glanced down at Ventura’s two-year contract renewal form, which was lying next to the stack of reviews that Prescott still needed to summarize on the department head’s ‘‘master’’ review form. (See Exhibit 7.) He would need to have a conversation with Ventura explaining his decision regarding contract renewal and giving him feedback and developmental advice.

He summarized his thoughts regarding Ron:

In the two years that Ron has been here he has hurt morale in the Vascular Surgery Division and more broadly in the Cardiovascular Center. There haven’t been any official reports made to HR about Ron’s behavior, but others don’t want to work with him because he’s hyper-critical of their work. Cardiac surgeons, cardiologists, and radiologists in the Cardio Center are upset with him because he always thinks he needs to drive the bus and he won’t listen, and because he has openly criticized the techniques used by other physicians. Nurses are intimidated by his authoritarian mandates. Even though no one can point to any actual harm to patients resulting from Ron’s behavior, and his patient outcomes have been excellent, surgeons still need to work collaboratively with other members of the medical staff in order to provide quality care. The leading cause of avoidable surgical errors is poor communication among the surgical staff, especially by the surgeon. No surgeon can do his job alone in the OR. If this goes too far, the hospital could wind up spending a million dollars a year in re-staffing efforts.

Prescott was responsible for meeting aggressive revenue targets in a Cardiovascular Center that was rapidly gaining national notoriety. Ron Ventura’s impressive caseload and superior outcome data in vascular surgery would go a long way toward helping Prescott meet those targets.

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

8 BRIEFCASES | HARVARD BUSINESS SCHOOL

Exhibit 1 Annual Performance Evaluation Data Packet

RON VENTURA, CHIEF——VASCULAR SURGERY

Strengths (representative examples of comments)

Individual Top-Down Comments Physician A (Chief Medical Officer)

Excellent reputation as an accomplished surgeon: Objectively speaking, he’s an excellent technical surgeon. The rates of complications in his cases are lower than most. He has the lowest rate of unplanned returns to the operating room in the center. Dependable/Accessible: I can count on him to take the toughest cases and he never says no. He’s here on the weekends. He’s always the first to volunteer to take call and never complains. We’ve never had a patient complaint regarding Ron’s care, and he follows all the treatment protocols and compliance guidelines without fail.

Physician B (Director of Medical Education)

Contribution to Mitchell’s reputation in Vascular Surgery and Cardiovascular Care: He’s improved the profile and reputation of the hospital. Generates revenue for hospital: He’s increased our caseload tremendously. He is the fastest and most deliberate surgeon in his field. He can do more cases than anybody else on any given day.

 

Individual Colleague Comments Physician C (Interventional Cardiologist)

Highly capable: He’s very smart. He and I can talk about any case and he always has something value-added to contribute. I hate to admit it but if I could only talk to one person in the center, and no one else about my most complex cases, that person would be Ron. Hard-working/dependable: He’s the hardest working surgeon at Mitchell. He’s always available in an emergency and he never complains about it. He’ll take on the tough cases that no one else wants to touch.

Physician E (Cardiologist)

Focused: Focused is the word that comes to mind with Ron. You never get the sense that he is distracted. He’s laser-focused on the job at hand and makes sure that he does the best job possible every time. I can’t say that for every surgeon here. Ron stands out on that dimension.

Physician F (Chief Quality Officer) None

Physician G: (Vascular Surgery Fellow)

Technically skilled: Dr. Ventura is a master of the craft. There are some days when I feel privileged just to be able to observe what he does. Even one of the nurses, who complains about him all the time, ended up referring a family member to him for surgery. I don’t like Dr. Ventura, but I respect him as a surgeon.

 

Note: Although most 360 degree review process require the evaluator to quantitatively rate an individual on a variety of dimensions, in its initial roll-out of the program, Mitchell decided to focus on qualitative feedback.

 

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 9

Individual Bottom-Up Comments Resident A (General Surgeon)

Excellent teacher/superior knowledge and skill: Dr. Ventura has taught me a lot. When I compare what I am learning just by observing him, versus observing other attending physicians, I realize that he has given me unbelievable exposure. However, he doesn’t let me do enough in the OR. Dr. Ventura is good at telling me what he is doing and why, but he only allows me to assist in his cases. He seems unable to relinquish any control. Sets high expectations for the team: Dr. Ventura pushes everyone to a high level of performance. He doesn’t settle for anything less than excellence. He doesn’t tolerate slackers and he makes sure that everyone is pulling their weight. Sometimes he’s too aggressive in his approach, but he does get everyone to fall in line.

Nurse A (Operating Room Nurse)

Confident/In control: As a surgical nurse I feel secure working next to Dr. Ventura because he knows what to do. I never get the sense that he is insecure or panicked. I don’t feel that same sense of security with other surgeons. Technically skilled: I’ve been in the OR a long time and Dr. Ventura is the most technically skilled surgeon I’ve ever assisted. He’s outstanding. Keeps me informed: Dr. Ventura is effective at communicating any change in orders/plan. He may not always tell me in the nicest tone of voice, but he’s good about keeping me informed.

Nurse B (Surgical ICU Nurse)

Clear directions/orders: There’s never any ambiguity regarding the orders that Dr. Ventura gives. He’s very clear. Decisive: Dr. Ventura always seems confident in creating a plan and executing it. He doesn’t waver like some other surgeons on the team. His confidence spreads to the other members of the team and, as a result, we all feel better about the approach we are taking.

 

Weaknesses / Opportunities for Improvement (Representative Examples of Comments)

Individual Top-Down Comments Physician A (Chief Medical Officer)

Source of administrative headaches: I’ve had to calm down staff——and even other surgeons and cardiologists——because of issues they have had with Ron’s behavior. I’ve had to make a lot of excuses for Ron, even when I’ve known that I simply cannot excuse his behavior. He needs to learn to treat his colleagues with a little more respect. I really like Ron, and I want him to succeed here, but sometimes I feel like I’m the only one who does. I realize he brought in millions for the hospital last year in his personal caseload alone, but he cannot expect the rules not to apply to him.

Physician B (Director of Medical Education)

Critical of the administration: Ron has been openly critical of the hospital’s administration, saying that the administration is wasting money on ‘‘feel- good’’ projects, when he needs new equipment in the OR. In a recent meeting, when we told him that a request he had made for new and very expensive equipment was put on hold by the CFO due to budget constraints, he stood up in the middle of the meeting and walked out without saying a word to anyone. When I tried to catch up with him after the meeting, he told me he thought that the administration was incompetent and that it was impossible for an ‘‘A surgeon to work on a team with C administrators.’’ Not a good behavioral role model for residents /fellows: We have responsibilities as a teaching hospital, and students are vulnerable to degrading remarks made by attending physicians. A harshly negative

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

10 BRIEFCASES | HARVARD BUSINESS SCHOOL

judgment from a respected surgeon like Ron carries huge weight and can make a resident drop out of a program. Ron’s track record hasn’t been great. Two out of the three residents he has trained have dropped out of the Vascular Surgery Residency. One resident reported complete lack of hands- on experience on his cases to the Residency Review Committee for Vascular Surgery. What I am most concerned about is that disrespect is a learned behavior in the clinical years, and these residents are learning that from Ron. Ron’s residents will emulate his behavior and the cycle will continue as long as such behavior is condoned.

 

Individual Colleague Comments Physician C (Interventional Cardiologist)

Openly critical of colleagues: Ron doesn’t think highly of one cardiac surgeon in the group, and we all know it. When Ron was recently urged to get the guy’s opinion on a case, he said that he’d rather get the opinion of a monkey than that surgeon’s opinion, because it would be more valuable. Ron doesn’t understand that we don’t disrespect other specialists in the group like that. He didn’t say it in front of anyone else, but the fact that he said it at all is totally unacceptable. Difficult personality: One of the nurses in the ICU told me she dreads it when Ron is the vascular surgeon on call. She admitted to me that she cannot complete a sentence when she calls him because he constantly cuts her off. This kind of treatment of nurses is not good for patients because it can adversely impact patient treatment.

Physician D (Vascular & Interventional Radiologist)

Doesn’t consider others’ points of view: Ron’s attitude is that it is either his way or the highway. He doesn’t listen to others. He expects everyone else to go along with his perspective on things, but he’s never willing to do the same. Not collegial: He doesn’t want to collaborate on anything within the group. When a couple of us asked him to participate in writing an article, he said he would but only if his name would be listed first. When I told him that another physician would be doing most of the data collection and analysis and that it wouldn’t be fair for Ron to be listed first, he pulled out of the project. We really could have used his patients’ data. He’s a smart guy and we wanted his involvement, but no one likes having their back pushed up against the wall. We could gain so much from Ron’s participation, but sometimes it just isn’t worth the hassle. Personal style issues: Ron doesn’t fit into the group. He’s pushy, aggressive, loud, and hard-edged. He’s just difficult to work with. I’ve seen firsthand that when he’s in a certain kind of mood, nurses and other staff have been shocked by his language and temper and the lack of respect he shows them. That can affect cooperation and our ability to deliver care as an integrated program. Judgmental: Ron can be really judgmental, rushing to an opinion before he has all the facts. In general, I respect Ron’s clinical judgment but he tends to be black and white about everything.

Physician E (Cardiologist)

Critical of colleagues: Ron seems to have no problem making gratuitous negative comments about other physicians’ care. A nurse told me that he apparently said to a patient that interventional cardiologists should only ‘‘mess with the heart’’ and ‘‘keep their paws off peripheral vascular work,’’ leaving it to ‘‘those who know how to get it done right.’’ These kinds of statements are unacceptable. It makes me and everyone else in the division very uncomfortable when we hear things like this. Ron injects toxin into the

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 11

team. Sets unrealistic expectations: While everyone here appreciates that Ron comes in immediately whenever called, he expects others to do the same. That’s just not realistic. Some of us have lives outside the hospital. He doesn’t lead a balanced life. Ron just bought a condo two blocks from the hospital so he can be here in five minutes; but, as far as I can tell, he eats all his meals here and sleeps here half the time anyway.

Physician F (Chief Quality Officer)

Passive disrespect: Ron declined to participate in a quality-improvement initiative that I was trying to get off the ground. He told me he would support the initiative but then refused to attend any meetings. When I asked him about it, he made up some excuses for why he missed the meeting but I found out that he had made some sarcastic comments to other surgeons about the initiative. He just doesn’t understand the way things work at Mitchell. We don’t treat each other like that. I feel like I cannot trust him at all. He says one thing and does another. That is concerning to me.

Physician G (Vascular Surgery Fellow)

Unwilling to delegate: It seemed as though Dr. Ventura undervalued the five years of surgical training I had elsewhere. He seemed completely disinterested in my progression. He always said that he had to put the patient’s interests first and that they needed a ‘‘trained hand.’’ When I asked him about being able to do more myself, he always has an excuse: ‘‘This case is too difficult’’ or ‘‘You haven’t had enough exposure to this technique. He always has to do everything himself and won’t give up control to anyone else. Narcissistic: He really thinks that he is better than everyone else here. He basically told me as much. It made me feel really uncomfortable because he seemed to be knocking the other surgeons by implying that he was the only surgeon I could really learn anything from. He acts likes he’s King Kong around here.

 

Individual Bottom-Up Comments Resident A (General Surgeon)

Abrasive personality: In my third month of training, I scrubbed in on a case and was observing and occasionally assisting Dr. Ventura. At one point he pulled a retractor in a way that indicated that he wanted me to take over retracting, but as I reached for the retractor, he forcefully pushed my hand out of the way, instead of verbally instructing me to remove my hand. Verbally abusive: My first week as a resident, I hadn’t met Dr. Ventura yet but went into the OR with another resident and stood in the corner to observe. Dr. Ventura walked into the OR and at one point noticed us in the corner and yelled at us telling us that when we come into the OR we’re supposed to introduce ourselves to the surgeon. He then pointed to another corner of the room and told us to move over there. I know of two residents who left the program because of Ron. On another occasion, I was assisting Dr. Ventura in a procedure when my arm accidently grazed the side of the table holding sterile instruments. Dr. Ventura yelled at me saying that I had contaminated the sterile field and that there was no room for clumsiness in the OR. I was embarrassed and nervous from that point on, and my arm started to shake a bit as I was assisting him. He commented twice more during the procedure that a surgeon needed steady hands and that maybe I ought to reconsider my career choice.

Nurse A Short-tempered: Dr. Ventura’s temper is the worst I’ve experienced from a surgeon in my 15 years as a surgical nurse. He has trouble controlling it at

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

12 BRIEFCASES | HARVARD BUSINESS SCHOOL

(Operating Room Nurse) times. Three months ago a more urgent case caused our case to be bumped from the OR, just as we were draping and prepping. Dr. Ventura said something about having tickets to a basketball game and then threw a catheter against the wall. It didn’t hit anyone but it made me think that I never want to be the one to deliver bad news to Dr. Ventura. Boundary issues with nursing staff: He has a reputation for casual ‘‘relationships’’ with nurses. I’ve never heard that he has harassed anyone but it makes me uncomfortable because one week a nurse will brag to me that she’s ‘‘with’’ Dr. Ventura and then a month later that same nurse is crying on my shoulder because he’s moved on. It creates weird tensions among the nursing staff. I wish there were a rule in the hospital against surgeons dating nurses they work with because sometimes you can cut the tension with a knife in the OR. It’s not good for anyone on the team.

Nurse B

(Surgical Intensive Care Unit Nurse)

Dismissive: Dr. Ventura never makes me feel as though I have anything valuable to contribute. His view is that I’m there to make his job easier. Just the other day, I mentioned to him that I thought that one of our patients in the surgical ICU might be developing an infection at the incision site. He told me that he had checked on the patient earlier in the day and that there was no infection. He looked at me as though I was an idiot. I found out that he went back again to check on the same patient. Then I overhead him later in the day sarcastically commenting to another physician that he wondered about the hiring practices of nursing staff at Mitchell because they seemed less capable than nurses in the hospital where he had worked previously. I was offended, and it’s going to make me think twice about what I communicate to him in the future. Insensitive verbal comments: Dr. Ventura once said during a case in the OR that the surgeon who trained him told him that the worst surgeons are left- handed females. He said that he always was ‘‘on guard’’ when he had to work with left-handed females in the OR so that ‘‘they didn’t mess anything up for him.’’ Thankfully, there weren’t any female surgeons in the room when he said it, but I was offended by the comment. Dr. Ventura is fond of talking about physical attributes he appreciates in women. The other day in the OR he commented about some Sports Illustrated swimsuit model whose bikini barely covered her body parts. It made all of us uncomfortable, because he wouldn’t quit talking about it. I think that he knows it bothers us, but he seems to like getting a rise out of us by making comments like that. I don’t come to work to listen to that. The administration or HR should do something to address this.

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 13

Exhibit 2 Culture of Safety——Joint Commission Standard LD.03.01.01

The new leadership standard on the creation and maintenance of a culture of safety acknowledges that ‘‘disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to patient care. Leaders must address disruptive behavior of individuals working at all levels of the organization, including management, clinical and administrative staff, licensed independent practitioners and governing body members.’’ Several elements of performance focus directly on identifying and addressing disruptive behavior:

• The hospital has a code of conduct that defines acceptable, disruptive, and inappropriate behaviors.

• Leaders create and implement a process for managing disruptive and inappropriate behaviors.

• Leaders provide education that focuses on safety and quality for all individuals. • Leaders establish a team approach among all staff at all levels. • All individuals who work in the hospital, including staff and licensed independent

practitioners, are able to openly discuss issues of safety and quality.

 

 

Exhibit 3 ‘‘Team Mitchell’’ Physician Compact

Part C: COLLABORATE ON PATIENT CARE DELIVERY

1. Focus on the patient. 2. Include staff, physicians, and management on team. 3. Treat all members with respect. 4. Demonstrate highest levels of ethical and professional conduct. 5. Behave in a manner consistent with group goals. 6. Participate in and support teaching. 7. Provide and accept feedback.

 

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | R

14

Exhibit 4

Exhibit

 

 

 

 

Ron Ventura at M

Physician Or

5 Integrated

Ca

Interven Cardio

Interv Rad

Mitchell Memor

rganizational

d Practice Uni

Pati

ardiology

ntional ology

ventional diology

rial Hospital

l Structure, Ca

it Concept for

ient at the Cen

BRIE

ardiovascular

r Mitchell’s Ca

nter of Our “Ca

FCASES | HA

r Center, Mitc

ardiovascular

are Universe”

C S

ARVARD BUSIN

chell Memori

r Center

”

Cardiac urgery

Vascular Surgery

NESS SCHOO

al Hospital

OL

 

 

Director, Cardiovascular Center

(A. Prescott)

Chief of Cardiac Surgery

(N. Singh)

2 Cardiac Surgeons

Chief of Vascular & Interventional

Radiology

(B. Klein)

3 Vascular & Interventional Radiologists

Chief of Vascular Surgery

(R. Ventura)

2 Vascular Surgeons

Chief of Cardiology

(H. McDermott)

6 General Cardiologists

4 Interventional Cardiologists

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

Ron Ventura at Mitchell Memorial Hospital | 913-572

HARVARD BUSINESS SCHOOL | BRIEFCASES 15

Exhibit 6 Typical Operating Room Team Structure for a Vascular Surgery Procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operating Room

General Surgical

Resident

Medical Students

Vascular Surgeon

Operating Room Tech

Vascular Surgery Fellow

Scrub Nurse

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.

 

 

913-572 | Ron Ventura at Mitchell Memorial Hospital

16 BRIEFCASES | HARVARD BUSINESS SCHOOL

Exhibit 7 Performance Evaluation Summary Review Form

Evaluation and Development Summary

Physician Evaluatee: Ronald Ventura Evaluation Director: Andrew Prescott Title: Chief Signature: Div / Dept.: Vascular Surgery Date:

Review of Performance

Evaluation themes:

Strengths: Comments:

1.

2.

3.

Development areas: Comments:

1.

2.

3.

Performance Development goals /objectives:

 

 

 

 

 

This document is authorized for use only by Mary Perkins (maje637@hotmail.com). Copying or posting is an infringement of copyright. Please contact customerservice@harvardbusiness.org or 800-988-0886 for additional copies.