“How is the BRAC going?”
Former President George W. Bush turned and asked as he strode towards the hospital’s main entrance on a warm summer morning in July 2006. He had just completed another of his frequent visits with the wounded troops and their families at Walter Reed Army Medical Center (WRAMC) in Washington, D.C. and turned to question the hospital’s commanding general and senior staff.
The General began to explain the progress made toward the closure of Walter Reed and the merger with National Naval Medical Center (NNMC) in Bethesda directed by the 2005 BRAC commission (Base Realignment And Closure).
President Bush interrupted him. “Are they keeping the name? That’s important. We have to keep the name.”
At that moment, for the Commander-in-Chief the success of the merger came down to the new facility’s identity: would it still be called “Walter Reed?” He was reassured that the name would remain, and satisfied, turned to leave. His question was perplexing at the time. But the fact that the new medical center’s name was debated by senior leaders for the next five years demonstrated that the President was more prescient than anyone realized at the time.
Twenty years ago Harvard Professor John Kotter published his research on why transformations fail in an article entitled “Leading Change.” In his model, the elements that predict failure were abundantly apparent as the Walter Reed Bethesda merger progressed. Yet, despite what might have been predicted, the merger was a success. Hospitals and health care systems can learn from this example, especially by asking why the merger was successful and even more importantly, who was ultimately responsible for the success.
A New Military Hospital
The Base Realignment and Closure Act of 2005 was the latest in a series of Department of Defense (DoD) reviews that date back half a century as the mechanism to close military installations. In May 2005 the BRAC commission’s latest list was made public and included a recommendation that called for the closure of WRAMC. It directed that the tertiary care clinical services of the Army medical center be consolidated and “realigned” with the Navy NNMC in Bethesda, Maryland. The name given to the consolidated Army-Navy hospital in Bethesda in the law proved to be controversial. “Walter Reed National Military Medical Center” (WRNMMC) combined the Army hospital’s eponym and the Navy hospital’s “national medical center.”
With the movement toward greater “joint” operations between military Services, it was decided that the newly named facility would also be the DoD’s first joint medical center. The decision to close Walter Reed was finalized in the fall of 2005, and a six-year deadline was set by law: the closure and consolidation was to be complete by September 15, 2011.
Setting The Stage
Walter Reed Army Medical Center opened its doors on the farmlands of north Georgia Avenue in Washington, D.C. in May 1909. Less than six miles from that site, the cornerstone for National Naval Medical Center on Wisconsin Avenue in Bethesda, Maryland, was laid by President Franklin D. Roosevelt on Veteran’s Day 1940, and the hospital opened for patients in August 1942. Both hospitals were considered the flagships of their respective Service medical departments. Both had provided care for Presidents and their families.
Although they were fiercely competitive, and each considered itself the “Nation’s Medical Center,” the hospitals shared a great deal in common. In this most recent conflict, the two medical centers had carried the weight of the war, caring for the majority of the war injured. Both WRAMC and NNMC practiced in the shadow of the national flagpole under the close scrutiny of the federal government. The hospitals were visited nearly every day by “suits, celebrities, and stars” including U.S. and international government officials, sports and entertainment celebrities, generals and admirals.
The hospitals both performed on a national stage and had been the subject of intense media scrutiny in the decades before the merger including the 1985 allegations of wrongful death were attributed to a surgeon at NNMC. In 2007 a series of Pulitzer Prize winning Washington Post articles uncovered inadequate housing and uncoordinated administration of care for wounded soldiers at Walter Reed. Nevertheless both hospitals and staffs were dedicated to quality care and had long histories of exceptional performance in Joint Commission surveys.
Both WRAMC and NNMC had made long-term commitments to intern, resident, and fellowship graduate medical education training (GME). And perhaps most importantly the hospitals represented the two most powerful “brands” in military medicine. Recognized around the world, the names were familiar to military and civilians alike.
Although WRAMC and NNMC had much in common, the 2005 BRAC law’s use the simple term “realign” to describe the institutions’ merger represented a significant understatement. Only later would it become clear that more than just realignment, a significant cultural transformation would be necessary. To make this transformation possible, the hospitals’ leadership had to recognize three key principles, initially identified by John Kotter twenty years ago.
First Principle: Establish A Sense Of Urgency
Kotter’s first principle is to establish a sense of urgency. Organizations need to embrace the idea that they must change to survive. Stakeholders have to be driven “out of their comfort zones.”
Yet at first, the only sense of urgency driving the merger of WRAMC and NNMC was the 2011 deadline established by the BRAC law. As a result, leaders from both services did not consistently embrace the need for change. The Army feared that the merger would undermine its world-renowned brand and the Navy feared losing its medical center’s distinct character and identity. As late as six months before the merger, voices from both Services argued that the closure and merger wouldn’t or shouldn’t happen.
Because the idea for closure and merger came from outside both organizations, neither could be confident that it had the requisite “seventy-five percent of staff members” who, Kotter says, must believe that business as usual is unacceptable. Two years into the project, and four years before the BRAC deadline, a senior uniformed commander was appointed to run a “Joint Task Force” headquarters established to oversee all BRAC related projects and military hospitals in the National Capital Region.
Unfortunately, because of the complexities of the Service budgets and the independent Service chains of command, the Joint command was not initially given sufficient authority over subordinates or the collective regional budget. As a result, he was not as successful as he might have been. Kotter wrote, “Change by definition requires creating a new system, which in turn always demands leadership.” For a variety of reasons the process lacked this “sense of urgency” and the leadership to inspire it.
Second Principle: Form A Powerful Guiding Coalition
The second key element for successful transformation is the creation of a guiding coalition to build a new culture. Initially, this coalition would include select senior leaders, but over time should evolve to include staff from across the organization. Again with some exceptions, senior leaders from both WRAMC and NNMC were unable to consistently come together in this way. This was due in part to frequent turnover in leadership. Bethesda had three CEOs and four COOs in the six years after the BRAC announcement. Walter Reed had four CEOs and three COOs.
At the same time at least seven different leaders from both hospitals headed integration efforts. Frequent leader rotation is common in the military health care system, and efforts were made to stabilize the final WRAMC leadership team. However, with divergent agendas among top leaders and frequent staff turnover at multiple levels, the team failed to unify to form a guiding coalition.
Formation of a guiding coalition also was hampered by the fact the most leaders did not fully appreciate the cultural differences between the organizations and their military services. For example, historically Navy leadership culture has been based on the tradition of the isolated command of a ship at sea, where mutiny and anarchy are the biggest threats. In contrast, on the battlefield, the Army operates in a state of controlled anarchy. Subordinate Army leaders are given their commander’s general intent and are expected to improvise and adapt amidst the chaos of battle. Differences between strong service cultures shaped the perceptions of the chain of command and overall operations.
To be sure, the organizations made efforts during the merger to account for cultural differences. Civilian consultants on cultural integration were brought on board but unfortunately most were not familiar with the differences in the hospitals’ organizational and military service cultures. Thus locked in a cultural scrum, both organizations lost the opportunity to align and create a solid guiding coalition. However, even more potentially damaging was the lack of a central, inspiring vision for the new medical center.
Third Principle: Establish The Brand
One year prior to the merger’s completion, the new hospital’s name still had not been agreed upon. At NNMC it was often referred to as “the new Bethesda,” and at WRAMC it was usually called “the new Walter Reed.” In an effort to secure the legacy and heritage of both brands, senior leaders at the merging hospital settled on the trade-name “Walter Reed Bethesda.” Despite this decision, the new medical center’s name remains a point of continued discussion and contention.
An organization’s logo is the single most important symbol of its brand. Yet, between 2005 and the summer of 2011, staff from each facility proposed at least 15 different logos for the new medical center. In the autumn of 2010, an outside consultant was hired and after extensive research with staff and patients, the Joint Task Force Commander approved a logo just eight months before the merger. As tensions continued, the logo was inconsistently adopted. In fact, the agreed-upon logo did not appear formally in the new medical center until after the merger (Figure 1). In practical terms, the lack of agreement on both the name and logo until after the merger was emblematic of broader and deeper struggles that muddled the new medical center’s identity, brand, and vision.
According to Kotter, in order for organizations to succeed in transformation motivated by a sense of urgency and led by a guiding coalition, they must cast and communicate a vision “of the future that is relatively easy to communicate and appeals to customers, stockholders, and employees.” Yet, neither the leadership of the two facilities, nor their services, nor the regional Joint headquarters shared the same vision for the new medical center. For example, some Navy leaders envisioned it as a network of specialists supporting a hub of patient-centered medical homes like NNMC. Meanwhile, some in the Army saw it as a global referral center for medical education, research, and ultra-specialty care similar to WRAMC.
A New Joint Organization
Over the past decade WRAMC and NNMC have consolidated into a single, two million square foot facility representing a new joint organization with robust primary care, worldwide, referral-based tertiary care, and translational research. This complex transformation required extensive renovation and new construction and involved the Nation’s two primary casualty care hospitals at the peak of war.
Today several years after the merger, the medical center cares for more than 40,000 primary care patients. At the same time in collaboration with the nearby National Institutes of Health and the Uniformed Services University co-located on the Bethesda campus, it is the largest tertiary care referral center in the DoD. A single compelling vision for the medical center and its campus continues to evolve. The leadership of Walter Reed Bethesda and the hospital’s overseeing command, the Defense Health Agency, continue the work of building a single, highly efficient, patient-centered academic health center that serves as the flagship of America’s military health system.
The merger’s progress is remarkable, given its challenging origins. It succeeded despite an inconsistent sense of urgency, the absence of a stable guiding coalition, and lack of a single, compelling vision. Prior to the merger ten integration staff and patient “measures of effectiveness” were established to monitor the integration progress. For example, hand hygiene was chosen as a reflection of compliance with newly merged staff procedures. Patient safety events and length of stay were chosen as indicators of patient outcomes. With minor variations less than a year after the merger, many of the “integration indicators” (e.g. hand hygiene, patient falls) had returned to baseline.
For example infection in battle-wounded service members is a significant risk factor that complicated the care of these patients early in the war. A system of rigorous isolation procedures and strict adherence to hand-hygiene were crucial staff practices. These procedures had to be carefully trained and monitored throughout the merger. At NNMC in anticipation of the merger, a system of “secret” observers was established on each inpatient ward. In the six months prior to the merger the average inpatient hand-hygiene compliance score was 86 percent. The compliance rate dropped to 71 percent in the months immediately following the merger but returned to baseline within months.
There were no significant staff or patient safety events associated with the merger, and several successful Joint Commission surveys since have praised the hospital’s staff and practices. So, if Walter Reed Bethesda’s transformation and cultural integration was able to succeed despite its early failure on multiple key principles, was Kotter wrong?
Not necessarily. It was in the facilities’ inpatient floors, operating rooms, and clinics where mid-level leaders and staff gained a true sense of urgency – not from a deadline imposed from outside, but instead from caring for desperately wounded, ill and injured service members from the combat theater and their families who arrived three times a week through the Air Force evacuation system throughout the six years of the merger.
The men and women who cared for these patients including nurses, doctors, therapists, administrators, enlisted medics, and corpsmen from all branches of the military, and career civilian staff became that guiding coalition. These professionals, many combat veterans themselves, were united in their dedication to these wounded warriors and committed to making sure that every patient and family member received the best care possible (seen in the above image).
Ultimately, the working vision of the new organization was embodied by the old WRAMC motto, “We provide Warrior care” and the NNMC statue of a Navy corpsman holding a wounded Marine that still stands in the lobby of Walter Reed Bethesda. The statue is named “Unspoken Bond.” This bond has become the foundation of the new medical center’s vision.
Caring for soldiers, sailors, airmen, and Marines became the ultimate imperative and reason for the merger’s success. Recovering service members in the facilities’ hallways served as visible, daily reminders of the medical center’s vision despite the chaos of relocation, construction, renovation, and cultural change.
Ultimately these men and women understood the urgency and formed the needed coalition. The Nation’s medical center has been transformed and continues to evolve.
Health care leaders will do well to remember that the most compelling vision of the future is the one inspired and driven by the men and women who directly touch our patients and their families.
Figure 1. The Transformation of Walter Reed Logos
Author’s note
The opinions expressed herein are those of the author and are not necessarily representative of those of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DOD) or the United States Army, Navy, or Air Force. Institutional Publication Review Board Approved.
Image Caption
Army and Navy nurses from Walter Reed Bethesda’s Ward 4 West celebrating the 2011 Army-Navy Game, four months after merger hospital’s merger.
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