ThedaCare Cardiovascular Care: Using a Compact Reboot as Fix for a Practice That Has “Merged, Not Integrated”

Case Study · December 22, 2016

At ThedaCare, a multi-hospital system in northeastern Wisconsin, an acquired cardiology group retooled its preexisting compact to facilitate its integration into the health care system. The retooled compact defined the mutual expectations of both the employed doctors and the system, encouraging greater candor, trust, shared accountability, and engagement.

Key Takeaways

  1. In any merger or acquisition, the importance of clear and mutual expectations for life together cannot be overstated. A common trap is assuming that a happy “marriage” will follow the “I dos.” Parties on both sides of the relationship carry expectations, which may or may not be realistic or shared, into the new structural arrangement.

  2. When integration does not progress as smoothly as expected or when distrust and suspicion tarnish a new partnership, all parties should be proactive in seeking to understand and address the causes. Avoiding conflicts and allowing them to build up will take a toll on trust.

  3. The honest dialogue that is the foundation of a codeveloped compact can ease strained relationships and clear the air. A compact that is developed through a transparent process can help providers make the transition from “me” to “we.”

The Challenge

In 2011, ThedaCare acquired Appleton Cardiology Associates, a 16-physician independent practice. Before joining the system, the Appleton Cardiology doctors governed themselves, made decisions expediently, and had their own distinct culture. Typical of physicians in such practices, they placed a high value on independence and clinical autonomy.

The Appleton Cardiology culture made it difficult for the doctors to shift toward and fully embrace system-wide thinking. In retrospect, retaining Appleton Cardiology’s CEO to manage the practice following the merger was not conducive to integration. While the doctors held onto a what’s-best-for-us mindset without appreciating their impact on the greater good, their manager reinforced the idea that they could simply fly under the radar and continue to do what they had previously done. In doing so, he avoided conflicts that should have been resolved, which stymied real progress.

Other differences contributed to tension as well. For example, as an early adopter of lean thinking, ThedaCare believes in seeking wide stakeholder input when making decisions affecting clinical practice. As a result, the decision-making process is more deliberate and, therefore, more time-consuming. In this new environment, the cardiologists felt that decision-making was taking too long. Another conflict stemmed from ThedaCare taking a system-wide view when redistributing income that has been generated. The cardiologists were wary of this attenuated link between what they “put on the books” and what came back to the division to reinvest in the practice.

By late 2014, new department and service line administrative leaders had assumed their posts. In 2015, Dr. Silja Majahalme, who had been sharing the clinical leadership role with another physician, was appointed Medical Director for Cardiology. However, angst was still running high among the cardiology providers and staff, and integration was still proceeding slowly, so outside help was enlisted to put the relationship on a better track.

The Goal

The ultimate goal was to integrate the cardiologists into the ThedaCare culture by building a better relationship through the formulation of a codeveloped compact.

The Execution

First Attempt to Formulate a Compact

Prior to merging, the Appleton Cardiology doctors had invested time in defining their responsibilities toward the practice and, in turn, what they could expect from the practice. The intent of this compact was to get the doctors to create a more cohesive group in order to enhance their reputation and be perceived as a dependable potential partner. The compact made explicit what behavior constituted good citizenship and what behavior would be considered out of bounds. It also identified what good governance would — and would not — look like.

While a good deal of effort went into defining reciprocal responsibilities, less went toward “nailing it down” through signatures or some other process to signify the official adoption of the compact. Once written down, the compact was not prioritized, and therefore it did not live up to its potential usefulness before the practice was acquired.

Second Attempt to Formulate a Compact

After the merger, the leaders of the cardiovascular division recognized the need to build a better relationship between the cardiologists and ThedaCare. To that end, a neutral facilitator was engaged to interview each doctor, and a trend emerged: a lack of trust between the doctors and ThedaCare.

ThedaCare Compact Excerpts

  Click To Enlarge.

During the interview process, the facilitator learned of the Appleton Cardiology compact and felt that it might be a way for the doctors to achieve a different relationship with the system. A series of evening meetings was scheduled for the purpose of considering the development of a compact between the cardiovascular division and the ThedaCare system. Momentum started high but dipped when the focus of the conversation turned to “improving our relationships.” Sensing this shift, the facilitator asked the cardiologists, “What sticks in your craw? What’s really bugging you?” These questions sparked energy, and the dialogue was off and running.

Over the course of 3 more evening meetings, the doctors discovered that much of their earlier compact could be modified and applied to their current reality. A challenging question was asked: How does this document not end up in a drawer, all-too-soon forgotten? One cardiologist suggested that each physician sign the agreement, and, in turn, the division leadership proposed that the system CEO also sign. The statement “I promise to deliver” represents a deeper and more meaningful commitment when individuals, including the CEO, literally sign the document. This step has in fact led the physicians, the leaders, and managers of the cardiovascular division to own the compact.

ThedaCare CEO Dean Gruner and each doctor signed the revised compact in June 2016. Implementing these agreements has led to vastly different feelings between division leadership and cardiologists, with a noticeable shift toward a sense of mutual accountability (Tables 1 and 2).


Since the compact has “gone live,” the doctors and the system have spent much less time renegotiating the terms of the employment agreement. The negotiations related to the employment agreements were completed in 2 months, which administration viewed as expeditious. The terms are for 5 years, not the original 3.

The administrative leadership of the cardiovascular division has seen an uptick in engagement in other initiatives since June. For example, cardiologists were fully engaged in an effort to increase patient access through one of ThedaCare’s lean initiatives: by stepping up and working collectively, they opened up an additional 500 slots for patient appointments. In addition, cardiologists are having more robust dialogues about improving clinical outcomes; rather than working in isolation, they now explore, as part of a multidisciplinary team, what they could do differently.

The compact was recently invoked, at a meeting of the ThedaCare Heart Institute’s governing group, as a tool to address a behavioral issue involving a doctor. Instead of making excuses for the doctor’s actions, one of the cardiologists referenced the compact, pointing out that it provided an applicable framework for the current discussion.

Dr. Silja Majahalme, the Medical Director of the cardiovascular division, noted that “Trust is an issue [that is] still circulating, but we have opened a dialogue around that. We are in a better, if not ideal, place. My goal for 2017 is to build up frameworks to support our compact, including evaluation tools and mechanisms to measure citizenship, performance, and behavioral issues.”

ThedaCare Examples of Supportive and Unsupportive Behaviors for Parties on Each Side of the Compact

  Click To Enlarge.

Where to Start

A rough patch on the journey to integration should raise a signal that there may be a misalignment of expectations between those who are being acquired and those who are making the acquisition. The first step is to have an honest discussion about what each party thought the “promises” were, what has been unsaid, and what expectations need to be clarified. Then the stage is set to codevelop, with candid and robust discussion, what the expectations of each party should be going forward.

To do this successfully, however, requires goodwill — going both ways — and enough trust to make and keep commitments. So, if the process that led to a signed merger document left bruises or lingering suspicions, then repairing those relationships with a focus on building trust has to be the first priority.

Lessons Learned

  • An acquisition is not automatically followed by a true partnership. A successful partnership requires a great effort after agreements are in place.
  • In the process of making a deal to bring a group on board, what is said — or implied — and what doctors hear may be different. Those negotiating a deal may consciously or unconsciously choose to downplay all the ways in which the merged practice will be expected to change, but that sends the signal that “business as usual is going to be OK.”
  • Any “we” versus “them” thinking, language or behavior — on either side — needs to be addressed immediately following an acquisition. Putting off these challenging conversations and assuming that “things will settle if given time” will not facilitate integration.
  • Don’t wait for tension to reach a boiling point. Proactively use whatever method or tool is helpful to identify mutual accountabilities. Eroded trust makes it harder to achieve an authentic partnership.

New Call for Submissions ­to NEJM Catalyst


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership

Reading List: Leemore Dafny and Stephen Swensen

NEJM Catalyst New Marketplace Theme Leader Leemore Dafny and Leadership Theme Leader Stephen Swensen weigh in on the most influential and inspiring readings of their careers.

Top-Down Implementation Process for Rapid Data Governance Adoption

Good data governance — a set of agreed-upon standards for gathering, formatting, and using data — is essential for health care organizations that want to tap into the power of their information.

Data Graphic: Cost and Coverage Impacts of the Better Care Reconciliation Act of 2017

Our breakdown of the Congressional Budget Office cost estimate of the U.S. Senate bill to replace the Affordable Care Act, compared to the U.S. House bill, the Affordable Health Care Act (AHCA)

Why Trump’s NIH Funding Cuts Would Be a Disaster

Undermining research funding will deplete medicine and science of the best and brightest minds and lead to a global destabilization with far-reaching impact.

Data Graphic: Health Care Drives Nearly One Million in Job Losses Under the AHCA

A recent study by the Commonwealth Fund on the economic and employment impact of the American Health Care Act (May 2017 version) shows almost one million job losses over the next 9 years, mostly in health care.

Reading List: Rushika Fernandopulle

NEJM Catalyst Thought Leader Rushika Fernandopulle weighs in on the most influential and inspiring texts of his career.

Treating Low-Income Individuals Is Our Obligation

The CEO of NewYork-Presbyterian discusses the policies, interventions, and perspectives required for making sure low-income individuals receive high-quality care.

Board Review and the Middle-Aged Doctor

Taking the boards as a middle-aged doctor offers a renewed perspective on one’s practice.

Reading List: Aaron Martin and Scott Weingarten

NEJM Catalyst Thought Leaders Aaron Martin and Scott Weingarten weigh in on the most influential and inspiring texts of their careers.

Letter to a Young Female Physician

One of the greatest hurdles you confront may be largely of your own making.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Economic Investment and the Journey to…

Early successes suggest that value-based purchasing programs can both transform employer-based health care and have…

Leading Transformation

167 Articles

We’re Not as Good as We…

Is the pace of change in health care going too fast, or too slow?

Leading Teams

118 Articles

The Importance of Leadership to Organizational…

Effective leadership is built on a solid foundation consisting of a clear mission, a vision…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now