Erick J. Laine, MD Executive Vice President and Chief Operating Officer UnityPoint Clinic

1. UPC: Creating a Physician-Driven Organization A New Paradigm for Org Decision-Making UPH Symposium Break Out Session April 29th, 2014 Erick J. Laine, MD Executive Vice President and Chief Operating Officer UnityPoint Clinic

2. UnityPoint Clinic-SA “UPC”- Trademark Meriter

3. UPC Size and Scope 1200+ 650+ 5400+ 25 Providers: 2700+ Employees: 100 Patient encounters: 75,000 2.0 million+ Annual Revenues: $10 M 4.0 million+ $300 million+ Previous State $700 million+ Current State Future State

4. UPC is something New. UnityPoint Clinic 1. New Name… 3. New Purpose… 4. New Structure… 5. New Processes*… 6. New Outcomes… 2. New Identity*… “Physician-Driven” Decision-Making

5. Healthcare “Climate Change” …. New VBC Environment Old FFS Environment “Value” (Triple Aim) 1. Performance Basis Volume 2. Payment Mechanism Fee-For-Service -Fee-For-Service -Pay-for-Performance -Partial Performance Risk Shared Savings Bundled Payments Warranty Payments Condition-based Payments -Full Performance Risk 3. Performance Risk a. Clinicalquality b. Access c.Cost-of-Care -Providers -Providers -Providers -Providers -Payers -Payers

6. Healthcare “Climate Change” …. New VBC Environment Old FFS Environment

7. Healthcare “Climate Change” …. “Un-Sustainable” “Sustainable” Crisis New VBC Environment Old FFS Environment 1. Individual Patients 2. Individual Providers 3. Individual Organizations Performance: Quality orAccessorCost 5. “Autonomy” Pt Populations / Care Coordination 2. Integrated, Team-Based Care Organized Systems of Care (OSC) Performance: Quality+Access+Cost 5. “Accountability” “Volume” “Value” “Low Order” Systems (cottage industry) “Higher Order” Systems (OSC) Time

8. Adaptive Change…. Old FFS Environment Necessary and Sufficient “Low Order” Systems (cottage industry)

9. Adaptive (Evolutionary) Change…. “Sustainable” “Un-Sustainable” Crisis New VBC Environment Old FFS Environment UPC OSCs UPH NecessaryandSufficient NecessarybutInsufficient “Low Order” Systems (cottage industry) Higher Order Systems Time

10. Shifts in “Organizing Entity” Name… Identity… Purpose… Structure…. Process… Outcomes… Individuals Systems (complex organizations) Organizations

11. “WhyUnityPoint Clinic … ?” Still necessary… Individual No longer sufficient… “You… Cannot… Do… It… By… Yourself...” (Anymore)

12. “WhyUnityPoint Clinic … ?” “Value” Performance

13. Lots of New Pieces… Putting it all together Senior Management Board of Directors CEO RPC Key Forums Key Positions (Key Forum Org Chart) (Key Position Org Chart) Regional Management PGC “Me” CFO Job Descriptions Charters Medical Directors Other Providers Physicians Managers Different Roles Standing Agendas Staff Committees “Administrators” Vice-Presidents New Responsibilities… New Accountabilities… New Relationships…

14. UnityPoint Clinic What… ? “Physician-Driven” Decision-Making Why… ?

15. “Physician-Driven” Organization The “physician” refers to an entity (or entities) comprised of actively practicing physicians who share the following characteristics: • Aligned with each other in mission, vision, values • Function together within a well-understood governance, leadership, management and committee structure • Maintain well-understood and consistent operating principles • Develop reliable lines of communicationfrom bottom-up and top-down Within UnityPoint Health, this entity (or entities) has meaningful and well-understood decision-making authority and advisory roles at both the regional and the system level. Approved by UnityPoint Health Board June 7, 2013

16. Physician-Driven ScorecardUnityPoint Clinic

17. UnityPoint Clinic

18. UPC Core Values • Patients First • Integrity • Pursuit of Excellence • Partnership • Community Stewardship

19. UnityPoint Clinic

20. “New Group” Org Structure… 2012 “Operations Committee” Board Comp Committee Payer contract Committee Finance Committee Practice Innovation Committee IT Committee Compliance Committee Peer Review Committee Policy Committee Mid-Level Committee Committee Structure

21. UPC Org Structure 2014 MD Governance Structure UPC Board PGC MD Committee Structure MD “Line Management” MD Senior Management “Alignment” System Level Regional Level Key Positions RPCs MD MD Key Forums Regional Management Role Clarification* * “Physician-Driven” MD Physicians and Staff

22. UnityPoint Clinic

23. UPC’s Decision-Making Process “Who makes decisions around here…?” “How are decisions made…?” “Why was that decision made…?”

24. Decision-Making Principle Expertise= Responsibility = Accountability = Authority

25. Expert Decision-Making Distinction Organizational Decision-Making Vs.

26. Expert Decision-Making Expertise= Responsibility = Accountability = Authority (decision-making) Clinical Domain Clinicians Operational Domain Administrators Financial Domain Finance Legal Domain Attorneys

27. Organizational Decision-Making Expertise= Responsibility = Accountability = Authority (decision-making) Clinical Domain Clinicians + Operational Domain Administrators + Financial Domain Finance + Legal Domain Attorneys Increasing Organizational Complexity Increasing Organizational Performance Risk Exposures Requiring Expanded Categories of Consideration Expert, Team-based decision-making across domains of expertise UPC

28. Organizational Decision-Making… II. Parties of Consideration I. Categories of Consideration Patients + Physicians Staff + + + + Reg/Legal Clinical Organizational Financial Operational + Hospital Regional OSC III. Periods of Consideration + + The Past… + The Present… The Future… UPC UPH “DIRTFT” “BOFEPET” “It Works!”

29. Organizational Decision-Making… II. Parties of Consideration I. Categories of Consideration Patients + Physicians Staff + + + + Reg/Legal Clinical Organizational Financial Operational + Hospital Regional OSC III. Periods of Consideration + + The Past… + The Present… The Future… UPC UPH “It Doesn’t Work!”

30. DIRTFT: “Doing It Right the First Time” ! “Bright Idea” Team-based synthesis “Compelling Concept” Realm of Ideas Finite Realm of Reality “Good Planning” Site Multiple sites “Pilot” System Wide Roll-Out (Real Innovation) (Big Ooops) “Demonstration Project” Not Liabilities… Grow Assets…

31. Organizational Decision-Making… Integrity: Actual results = Pledged results “Priorities”: Future State vs. Current State “Stretch” Current State

32. Organizational Decision-Making… The “Circles of Hell” (Levels of Over-Commitment) Criminal Cynical Resigned Fantasy Hopeful “Stretch” Current State

33. Organizational Decision-Making… Avoiding the “Circles of Hell”: Options (Desired) Feasibility Testing (“Reality” Tests) Priorities Current State (Real) Growth… Development… Hopeful Fantasy Resigned Cynical Criminal

34. Role Clarification: Organizational “Agency” Org Responsibility : Org Accountability : Org Directive Authority Question: Who has organizational directive authority (the ability to commit and direct members of the UPC)? Agents • Answer: • Key UPC Positions • Executive officers • Directors • Delegated agents • Key UPC Forums • Board of Directors • Executive Teams • Management Teams

35. Role Clarification: Directive Authority Org Responsibility : Org Accountability : Org Directive Authority Org directive authority: Officers, Managers Agents and Employees Clinical directive authority: Physicians

36. UPC Decision-Making Process • I. Candor • A. Honesty • B. Openness • C. Listening

37. UPC Decision-Making Process • I. Candor • II. Decorum • A. Discussion… • B. Debate… • C. Argument… • D. Professionalism (attack issues, not people) “Professional”

38. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • A. “Categories” of Consideration • B. “Parties” of Consideration • C. “Periods” of Consideration • D. Constraints (“reality”) • E. Desires < Wants < Needs < Priorities “Fair” “Sophisticated” “Feasible” “Reasonable”

39. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • A. Organizational decisions (agency) • B. Recommendations (advisory)

40. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • IV. Tasking / Direction / Delegation • A. Delegation • B. Precision • C. Prescription • D. Time frame • E. Explanation (“Who”) (“What”) (“How”) (“When”) (“Why”)

41. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • V. Tasking / Direction / Communication • VI. Commitment • A. Clarification: • B. Agreement: • C. Commitment “Do you understand?” “Do you agree?” “Can you commit?”

42. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • V. Tasking / Direction / Communication • VI. Commitment • VII. Action (Management, not micro-management) (Traction…)

43. UPC Decision-Making Process • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • V. Tasking / Direction / Communication • VI. Commitment • VII. Action • VIII. Follow-up (accountability) A. Performance Review / Assessment 1. Promised Trust Fidelity…Integrity…Credibility 2. Actual B. Revision C. Consequence Individually… Organizationally… 1. Positive 2. Negative

44. Decision-Making Process: Comments • 1. Decisions made by deliberate due-process are binding. “Glue” a. Basis of trust for those who lead… b. Basis of trust for those who follow… • 2. All individuals are obliged to accept decisions made… a. In the interest of all stakeholders… b. In fair, open process… c. In good faith… with due-diligence * Whether or not it comports with one’s individual opinion. • 3. If process defaults to “back-room” decision-making… a. It erodes the basis and willingness of individuals to commit to org work… (“waste of time”) b. It erodes the rational, objective basis for individuals to engage meaningfully…

45. Decision-Making Process: Comments • 4. All UPC members are asked to respect and honor this process. Because, when these principles are not respected… a. Decision-making defaults… Inefficiency… Waste… - To special interests and political motives… - To revisiting the same issues over and over again… b. It undermines UPC’s ability to make well-grounded decisions and get work done… c. It reduces UPC’s ability to be high performing and successful… • 5. The decision, once approved, may be revisited at a future time… a. But not until there is cumulative evidence that the decision was made in error… b. UPC may make (will make) small mistakes…but reduces the likelihood of big mistakes. c. In this fashion UPC moves forward…

46. UPC Decision-Making Process: Process Summary • I. Candor • II. Decorum • III. Due-Consideration • IV. Decision-points • V. Tasking / Direction / Communication • VI. Commitment • VII. Action • VIII. Follow-up (accountability) Process-based (team-based) Individual-based

47. UPC Decision-Making Process: Significance 1. Strategic Planning… 2. Physician Recruitment…

48. Physician Recruitment Process (Selectivity) …. UnityPoint Clinic (“High-Performance”, “Excellence”) “A” Team “Warm bodies” “IQ” “EQ” “RQ” Assets Liabilities Back seat critics/cynics Least-common denominators Driven only by self-interest… Innovators and collaborators Contributors to high-performance Shared identity, intents, purposes… Recruitment Retention..

49. UPC Decision-Making Process: Significance 1. Strategic Planning… 2. Physician Recruitment… 3. Practice Acquisitions… 4. Program Development… 5. Growth, Staging, Pacing… 6. Organizational “Priorities”… Internal and External Implications

50. In Summary... New Reality… Cost-of-Care Quality Access UnityPoint Health-System Patients UnityPoint Clinic Payors Decision-Making “Physician-Driven” Collaborators Region More Rigorous Process Communities New, Expanded Relationships Group New, Expanded Roles MD