A Profile of CNSA at a Time of Leadership Transition
Colleagues: For the past 20 years, the authors have had the privilege of helping direct the growth and development of one of the leading neurosurgical practices in the nation. As CNSA transitions to a new generation of surgeon leadership, we offer the broader neurosurgical community these reflections on lessons learned during an unprecedented period of progress and prosperity for this group, now in its 82nd year.
CNSA- The Benefits of a Constructive Culture
Carolina Neurosurgery and Spine Associates (CNSA), based in Charlotte, NC, was founded in 1940 and has since developed into one of the largest and most influential neurosurgical practices in the United States.
During our tenures as president and CEO of CNSA, we have observed numerous examples of positive strategies for practice development and performance improvement. Of course, we have also witnessed our share of seemingly promising strategies that ultimately became failures. Like businesses in most other sectors of our economy, achieving a healthy balance between risk and reward has been necessary for us to create a successful, sustainable practice structure.
Perhaps most importantly, we have gained clarity on attributes predictive of successful physician leadership. In that regard, we have been and remain firm adherents to Drucker’s oft-quoted maxim that “culture eats strategy for breakfast”.
Hiring neurosurgeons who can thrive in practice and successfully fit into an established culture is not always simple. At CNSA, we have certainly had hires who failed, but CSNA has arguably been successful in talent retention and practice expansion. We attribute this success to continuously improving our recruitment process and placing equal emphasis on surgical skill and efficiency, along with personal characteristics congruent with our culture.
In an environment where most of our members have trained at highly regarded residency programs throughout the country, we have learned that the creation of a thriving practice correlates more directly with emotional quotient, communication skills and the ability to relate to patients and families more than pure technical proficiency. In that regard, we have iteratively improved our due diligence and we depend heavily on word-of-mouth referrals from trusted colleagues for direct, experiential information about the disposition, collaborative potential and personal ethics of potential new partners. We have specifically focused on balancing the subspecialty and site-specific needs of our practice with the primary traits we believe are necessary for neurosurgeons to succeed in a large group practice:
- HUMILITY
- SURGICAL SKILLS AND EFFICIENCY
- CONFIDENCE (WITHOUT ARROGANCE)
- LEADERSHIP QUALITIES
- COMMUNICATION SKILLS
- TEAM-FOCUSED ATTITUDE
Although it might be reasonably assumed that the specialty of neurosurgery, given its unique demands, in combination with a seven-year training program, would self-select for these qualities; that regrettably is not uniformly the case.
A majority of large companies in professional fields outside of clinical medicine utilize personality testing in their screening process for hires. We have not used such testing to date. The hiring of new physicians requires a unanimous vote of the existing partners. Group decisions on hiring are traditionally based on perceived demand, utilizing wait times and growth strategies as metrics to more objectively balance practice needs with talent. Although we typically hire for anticipated subspecialty and geographic requirements, we have generally not failed when we encounter “can’t miss” candidates possessing an ideal mix of clinical aptitude and personal qualities, even in years when immediate subspecialty “need” or timing for growth is not certain. We have found that such an individual will quickly succeed in practice and contribute, regardless of market conditions.
Although we have placed a premium on finding high-quality neurosurgeons who function well within our practice culture, we do not find that custom to be inconsistent with promoting independent thought and opinion. On the contrary, it is vital that all of our members form strong opinions and remain highly motivated to succeed independent of cultural incentives. We do, however, encourage the development of skills that promote cooperative problem-solving and work that is oriented towards decision-making of benefit to the whole practice, not merely individual members.
As CNSA has expanded, it has become less and less likely that any one issue will gain unanimous group support, and the requirement for compromise and harmony has become paramount. Much like a team sport, the group goal is to maximize individual returns while simultaneously achieving a victory for the “team”. Decisions within the practice are driven by consensus with majority support. It is imperative that “team philosophy” is exhibited not only at the physician level, but also among our broader employee group, along with our hospital partners and administrative team. The ability to manage the stress of our specialty, while maintaining a positive outlook and being relational with our extended team inside and outside the hospital, has directly correlated with long-term success in our practice and has consistently added value to the communities we serve.
CNSA and the Importance of Leadership
Our specialty is fortunate to attract an abundance of talented individuals who are natural leaders and can assume multiple positions and interests over and above a successful, busy practice. Such leadership has long been associated with the continued health and vitality of our field.
As a prominent regional practice with multiple clinical sites and close ties to Atrium Health, our primary acute care health system partner, we have found it essential that most of our physicians are involved in, and accountable for, a wide spectrum of leadership activities. Local hospital, national and group leadership roles foster growth, professional development and expansion of practice influence and impact. Leadership training, an essential embedded element within our culture, additionally creates a significant pipeline of future leaders for our practice and our specialty.
Through our various leadership roles, we have been able to promote collaboration as the winning formula with Atrium Health. That cooperative approach, virtually always associated with the development of significant mutual benefit, has allowed for the development of numerous successful joint ventures including, but not restricted to: a neurosurgical residency training program, an emergency neurosurgical care program, a corporate bundled-care spine program and directorships of a comprehensive regional spine service line, along with a region-wide (i.e., multi-state) neuroscience institute.
It is worthwhile to elaborate on a few examples of those joint ventures, highlighting the leadership that extends outside of the clinical realm to create a partnership with Atrium Health. The triple aim of healthcare requires partners across independent practices and health systems to support the shift of patients into lower-cost settings safely and with high quality. As such, in 2006, a joint venture for ambulatory outpatient spinal surgery was established and has proven highly successful. This venture created significant shared trust, which was leveraged to advance other projects. The value of that partnership was further demonstrated in 2012, when our group developed a substantial presence in the creation and implementation of national clinical databases. That embedded expertise provided the foundation for a contractual agreement on shared data collection, which has allowed us to mutually “prove value” and establish “centers of excellence status” attractive to corporate clients. We subsequently expanded our evidence-based, patient and value-focused spine surgery programs through the creation of a region-wide, multi-specialty spine care delivery system, which continues to evolve. Most recently, the strategic combination of our primary healthcare partner system with another large academic system in our state, possessing its own well-established neurosurgical team, training program and reputation of excellence, has and will continue to foster further cooperation and innovation toward system success.
CNSA – Lessons Learned Through Recent Macro-Environmental Challenges
Of course, when economic conditions are strong, practice management is relatively easy. During more challenging times, however, difficulties have developed both internally and externally, the latter in particular regarding hospital partners, payers and regulatory pressures.
The COVID 19 crisis was a recent example in which an unexpected global societal problem proved a real threat to care delivery and business success. Trust among partners and shared culture were of utmost importance in formulating a revised business plan and working with staff and administration on a successful strategy to allow us to remain fiscally sound while continuing to deliver high-quality care. In addition, we, like many other specialty services that remain primarily hospital-based, experienced during this crisis difficulties associated with our hospital partners’ unprecedented challenges in the areas of increased staffing demands, supply scarcity and bed shortages. Again, we were able to use our shared history of cooperation to appropriately recognize their unique stressors and successfully communicate and work with them to develop a strategy to effectively deliver care. This experience reinforced our pooled trust and has further strengthened our relationship – a condition that is likely to pay dividends for our organizations and the patients we serve going forward.
Internal group issues also arise and provide unique threats to practice culture. With respect to rare interpersonal issues, we have utilized a reasoned approach to communication with involved parties, with a goal of transparency and concise conflict resolution. In most situations, a group-first approach, led by consensus, can successfully resolve conflicts and both maintain and reinforce a “positive” culture. Likewise, when the group has made business or practice mistakes, we have chosen to openly recognize these events, resolve them, and move on with greater shared wisdom. Innovation has been key to our success, but with innovation comes risk, and with risk, there will inevitably be missteps.
Summary
In the 82-year history of CNSA, a tremendous foundation has been established for superior patient care and delivery. The culture and traditions that have been intrinsic to the fabric of this organization since its founding, the explosive growth of the Charlotte metropolitan region, combined with the evolution in healthcare delivery, along with the vitality and import of our unique specialty, have enabled our group to experience tremendous growth over the last 20 years. In 2023, CNSA is a sophisticated, independent multi-specialty practice of 49 physicians (36 neurosurgeons/2 orthopedic surgeons, 11 physiatrists), 38 mid-level providers and more than 450 employees. CNSA physicians currently have more than 220,000 patient encounters per year and perform more than 10,000 surgeries per year a roughly four-fold increase in our ability to serve this thriving community over the past two decades.
We have worked cooperatively with our primary hospital partner, Atrium Health, to foster a thriving residency program, a large outpatient destination spine center and a comprehensive approach to the growth of the neurological and spinal service lines of the future.
A successful culture has been at the forefront of our success, fostered by strategic hires utilizing a team-first approach, with excellent communication and transparency. A dyad leadership model with a physician president and board chairman and a non-physician CEO has provided an organizational structure best able to manage internal and external successes and failures. Future strategies for success will be centered on data-driven innovation, quality and consistent care and business partnerships focused on trust and mutual gain.
