| “Unifying our organization over the past 21 months, as with most mergers, has been challenging and we are far from finished.” |
Change management is both the art and science of preparing, supporting and equipping individuals, teams and an organization to adopt and adapt to new beginnings.
Given the landscape of rapid and relentless change, successfully managing change is critical to leadership in healthcare today. At Duke Health, the integration of the physician practice, formerly termed the Private Diagnostic Clinic (PDC), tested our change management prowess, and there are countless lessons learned that we are still benefiting from as our journey continues.
The PDC, established in the 1930s, operated as an independent, for-profit PLLC physician practice for nearly a century. It evolved into one of the largest independent faculty practices in the U.S., with nearly 2,000 physicians, 18 clinical departments, 3,000 staff members and over $1.2 billion in annual revenue. Despite close ties to the Duke University Health System (DUHS) and the Duke School of Medicine, where PDC members provided clinical care, research and training, a separate and non-fully integrated faculty practice impeded optimal collaboration, agility and strategic growth.
Recognizing the need for a unified structure, all three entities co-created a cohesive “new” Duke Health. The goal? To unify and position Duke Health to successfully tackle the issues facing all health systems today while maintaining our leadership in extraordinary patient care, research, education and community health. In April 2022, the physicians voted to dissolve their independent practice, leading to the creation of Duke Health Integrated Practice within DUHS and the University in July 2023.
Unifying our organization over the past 21 months, as with most mergers, has been challenging and we are far from finished. However, it has already been a transformational change for Duke Health, catapulting us into a season of rapid growth and advancement. Successes include:
- Record clinician recruitment
- The lowest provider turnover rate in years
- Higher physician compensation and more transparent compensation plans
- The lowest physician burnout rate since 2017
- Strategic and operational alignment via a co-created management/leadership system
- Increasingly efficient operations and more rapid and diversified growth
- A renewed culture of respect and belonging
Lessons Learned
As we reflect on this significant change for our organization — things that went well and those that did not — there are several lessons learned that may be helpful for healthcare leaders when undertaking change of this magnitude.
1. Create a Compelling Shared Vision
Fundamental to big organizational change is creating a clear, compelling vision of the future state that motivates, inspires, provides direction for the change, and enhances buy-in from stakeholders. In a merger such as this one, it was essential that this vision be shared between members and leaders of the physician practice, health system and school of medicine. Leaders of all entities needed to be aligned with and articulate “the why” and “why now” in a way that was consistent and represented a unified vision of a new Duke Health. The “why” included particular attention to how the integration would enhance the unique focus of an academic medical center. This message was embedded every step of the way. A strong super-majority vote for integration underscored the collective belief in the vision and created momentum for execution.
2. Co-Create the Future
Successful change isn’t dictated — it’s co-created. Co-creation allows you to tap into the collective wisdom and creativity of all stakeholders. In the lead-up to the integration, leaders of the physician practice, health system and school of medicine jointly negotiated the operational, legal and financial framework of the new combined organization. Joint functional and strategic transition teams with broad representation from all parties were formed to plan and implement the merger. This structure allowed issues to be resolved with a broad perspective and by those “closest to the work.”
We also identified change champions, including key department chairs, early on and engaged them to encourage their colleagues, further strengthening collective ownership. This structure was replicated post-merger as we co-created a new management structure that gave voice to the new practice, produced physician leadership opportunities and clarified where decisions were being made and pathways for problem escalation.
3. Put Culture Front and Center as a Non-Negotiable
Far too often, mergers prioritize operational and financial integration while neglecting culture. The so-called “soft stuff” gets lip service, but true cultural transformation is frequently overlooked — a costly mistake. No matter the size of the merger, culture is the foundation of an organization. Get it right, and everything else follows.
Recognizing this, we launched a comprehensive, multi-year culture transformation journey in the months leading up to the merger. This effort required broad participation from providers, the health system and school of medicine. We began with extensive listening — conducting leader interviews, focus groups, and interactive virtual “dialogues” that captured the voices of more than 4,000 people. Through this process, we identified the best aspects and core values of each organization, shaping a shared vision of a culture we aspired to have. This collective effort not only defined our aspirations, but also guided us in adopting new behaviors and ways of working as a unified team.
To turn vision into action, we implemented workshops, training, and an omnichannel communication strategy. A set of cultural commitments and associated behaviors were developed and incorporated throughout the organization, which are now embedded in our new team member and physician orientations as well as our performance coaching discussions. While we are still on our cultural transformation journey, identifying culture as a non-negotiable and putting it at the front and center at the beginning of the integration of the physician practice has been a critical ingredient to our success.
4. Communicate Clearly, Consistently and Often
Change breeds uncertainty, and uncertainty breeds assumptions. The only antidote? Clear, consistent, and frequent communication.
People experiencing change want answers to three fundamental questions: What is changing? Why is it happening? What’s in it for me? As leaders, we tend to default to the positive, which is important, but being pragmatic and realistic will add to one’s credibility. As much as the collective leadership believed in the vision, we acknowledged over and over that this change will be hard, there will be bumps in the road, not everyone will get what they want, and that there will undoubtedly be folks who choose not to be a part of the new organization (which indeed happened).
Early on, we underestimated the importance of frequency and timing. We aimed for polished, all-encompassing, “perfect” messaging. However, in the pursuit of perfection, the resulting delay or lack of communication created uncertainty, anxiety and negative assumptions. Eventually, we shifted our approach — opting for timely, transparent updates, even when all answers weren’t available. Leaders were vulnerable and learned that it was okay to say, “I don’t know, but I’ll let you know once I find out.” Timeliness and following up were key to building and maintaining trust.
Healthcare organizations are complex, and because of that, you need to understand who the trusted spokespeople are for specific audiences, what the preferred channels for receiving information are, and if there are any messaging nuances to consider when communicating with different audiences. We quickly learned the importance of identifying the right messengers and tailored our outreach. Department chairs, for instance, played a key role in bridging the gap between leadership and faculty. To ensure they had the tools to communicate effectively, we provided them direct support from communication teams. We also had to ensure they had a clear understanding of the messaging they’re delivering to avoid conveying only part of the messaging or, worse, misconstruing the message, leading to transparency and clarity issues and, ultimately, mistrust. Consistency in messaging across leadership was essential to minimize confusion and build trust.
We also used numerous channels to keep people informed. A central website served as the single source of truth, offering FAQs and timely updates. Bidirectional virtual and in-person town halls — some large, some small — gave audiences opportunities to ask questions directly. Emails, leadership videos, a dedicated inbox and surveys ensured concerns weren’t just heard but addressed. Most importantly, we maintained message consistency, regardless of the mode of transmission. This level of alignment was crucial in preventing misinformation and reinforcing trust throughout the integration process. To be clear, we did not always do this well — the majority of our missteps were related to lapses in communication.
5. Listen and Keep Listening
Listening is crucial in change management as it builds trust, allows for empathy, and helps leaders address concerns, leading to smoother transitions and employee buy-in. We engaged in extensive listening across both organizations through various channels mentioned above, providing mechanisms for direct and anonymous input from those affected by the change. Leaders continually asked, “How are things going? What are you experiencing? What is going well and where are things not going well? What ideas do you have for improvement? How can I help?”
Department chairs faced significant changes during this process. Previously, they led the PDC’s Board of Managers and independently managed finances, hiring and operations. Post-merger, their independence decreased, requiring navigation of new bureaucratic, financial and legal structures, especially moving from a for-profit to a non-profit organization. About 8 months after forming the new organization, many department chairs felt that their vision of the merger was not being realized. “Listening deeply” and addressing this frustration was a pivotal moment in our journey.
6. Be Prepared to Pivot
No plan survives first contact. Anticipating the need to adapt to changing circumstances and pivot in a new direction is critical to successful change management. As the aforementioned frustrations escalated, we could have reacted a bit earlier.
Escalating concerns from department chairs, particularly around decision-making authority, decision rights and finances, eventually rose to the fore about 10 months after forming the new organization. This necessitated a leadership “look in the mirror moment” and a two-day offsite retreat was held for the department chairs and senior leaders across Duke Health.
Health system and school of medicine leadership and the department chairs productively (but with healthy conflict) recommitted to the unified vision and culture and co-created a new, “flattened” management structure that includes the department chairs and other senior leaders all in the same room for strategy, operations, and mission discussions and decisions. This retreat resulted in greater alignment and a more nimble and effective organization — it was a pivotal point for the newly integrated organization.
7. Celebrate Big and Small Successes
One of our biggest lessons has been the value of achieving and sharing successful results. As Dan Heath notes in his recent book, Reset: How to Change What’s Not Working, “Of all the things that can boost emotions, motivation, and perceptions, the single most important is making progress in meaningful work.” Celebrating big and small successes created optimism, buy-in and momentum in our ongoing change journey.
Our integration journey isn’t over, but these practical lessons — vision, culture, communication, persistence, listening, adapting and celebrating — continue to serve our roadmap for the ongoing integration and are lessons that all healthcare leaders can learn from as they respond to the ever-changing world of the healthcare sector.
Craig T. Albanese, MD, MBA, is CEO of Duke University Health System — North Carolina’s fourth-largest employer and one of the nation’s top academic medical centers. A respected surgeon scientist and clinical investigator, Dr. Albanese is responsible as CEO for strategic and operational oversight of DUHS and its senior leadership. He joined DUHS as executive vice president and chief operating officer in January 2022 and was named chief executive officer in February 2023.
