Abstract

Purpose

Charged particle facility design and operation presents numerous challenges, both technical and operational. The Mayo Clinic Proton Beam Therapy Program (PBTP) will consist of 2 proton radiation therapy facilities, each with 4 treatment gantries and 1 fixed beam room, located in Rochester, MN and Phoenix, AZ, respectively, operating under a single organizational structure. The proton facilities will open in 2015 and treat approximately 2,400 patients per year when fully operational.

Materials and Methods

To facilitate development of a unified organizational culture for the Mayo Clinic PBTP, a survey consisting of open ended queries regarding facility design and organizational culture was sent to 36 charged particle treatment facilities worldwide and analyzed using McKinsey's 7-S model of organizational values. The survey was also given to the Mayo PBTP planning group.

Results

The survey revealed the external respondents felt that aspects of organizational culture involving management style and staff contributed most positively to the success of their facilities, whereas internal respondents concluded that management style and structure were of greatest importance. Organizational culture decisions related to strategy contributed most significantly to a perceived lack of success.

Conclusions

The results of this survey would suggest that careful attention to recruitment or development of staff that embrace technological change with the necessary technical skills to allow them to confidently adopt proton radiation therapy are important components in designing a proton radiation therapy program. The survey also suggests that strategic decisions regarding resources and business model alignment may most negatively impact departmental culture.

Introduction

The Mayo Clinic, founded in Rochester, MN, is the largest integrated medical practice in the world. The Mayo Clinic Department of Radiation Oncology operates as part of an integrated oncological practice in conjunction with colleagues from medical oncology, surgery, hematology, and other services. Mayo Clinic's mission is “to provide the best care to every patient every day through integrated clinical practice, education, and research” [1]. Mayo Clinic possesses a strong organizational culture based on a unique brand of medicine which values excellence in clinical practice, education, and research

Mayo Clinic is currently constructing 2 nearly identical proton radiation therapy centers at the Mayo Clinic group practice sites in Rochester, MN and Phoenix, AZ. The facilities will consist of 4 treatment rooms each, capable of treating 2,400 patients per year in total. In order to provide guidance as these facilities were designed, an external survey of charged particle facility operations internationally was conducted to determine which aspects of facility design and organizational structure might foster or hinder promotion of Mayo's primary values and integration of the facility into the group practice. The results of this poll were compared with internal responses to the poll to determine if current planning priorities matched outside experiences.

Materials and Methods

The survey instruments were prepared using the Research Electronic Data Capture Survey instrument [2]. Data was anonymously collected after institutional review board approval.

Recruitment emails were sent to 36 charged particle facility representatives identified through the Particle Therapy Cooperative Group membership list, 10 in North America, 16 in Europe, and 10 in Asia in November of 2010. The survey was sent to both carbon ion and proton radiation therapy centers. The survey was also given to the members of the Mayo Clinic Proton Beam Therapy Program planning group. Survey participants were first asked 4 demographic questions regarding profession, continent of residence, employment status with regards to Mayo Clinic, and the status of the their facility (i.e. treating patients, in-planning or under construction).

They were asked to answer 6 open ended questions regarding facility design. The first 5 questions of the survey, which focused on organizational culture and facility design, will be the focus of this report:

  1. 1.

    Which aspects of your institutional or departmental culture have promoted or could promote success of your charged particle facility?

  2. 2.

    Which aspects of your institutional or departmental culture have hindered or could hinder the success of your charged particle facility?

  3. 3.

    Which aspects of your facility design have promoted or could promote success of your charged particle facility?

  4. 4.

    Which aspects of your facility design have hindered or could hinder the success of your charged particle facility?

  5. 5.

    If you were able to redesign your facility or change your organizational culture at this point in time, which area would you focus on for improvement?

The results were then compiled in the lists presented below. Responses relating to culture in questions #1 and #2 were anonymized and subjectively categorized using McKinsey's 7-S model of organizational culture (Figure 1). A relative weight was calculated for each variable in the 7-S model for these questions by subtracting the number of negative responses from the positive responses in each category of the 7-S model in order provide a qualitative measure of which categories were most consistently reported as either positively or negatively relating to organizational culture, i.e. 6 positive responses and 1 negative response in the “style” category would yield a summed relative weight of +5.

Figure 1.

McKinsey's 7-S Model of Organizational Culture.

Figure 1.

McKinsey's 7-S Model of Organizational Culture.

For the remaining questions, #3-#5, the responses were anonymized and reported below without summation.

Results

There were 23 respondents to the survey between November 11, 2010 and November 29, 2010. 13 (57%) were members of the Mayo planning group and 10 (43%) were from external facilities, for a response rate of no greater than 28% (10 of 36) for external groups. 16 (70%) of responders were physicians, 6 (26%) were physicists, and 1 (4%) was an administrator. The majority, 17 of 23 (74%) resided in North America. Three (13%) were from Europe and Asia, respectively. Seven of 23 (30%) were working at facilities actively treating patients and 16 (70%) were at facilities in planning or under construction.

Responses from groups external to Mayo to the survey questions are shown in the following paragraphs in text. A numerical indication of a multiple value indicates the number of times an answer was repeated by respondents. The descriptor in parentheses corresponds to which category of the McKinsey 7-S model the response indicates. Figure 2 presents a quantitative assessment of which aspects of the values in the 7-S value system appeared as positive and as negative responses most consistently.

Figure 2.

External respondents' view of the differential impact of organizational culture factors on charged particle facility operation from external respondents analyzed using the McKinsey 7-S model. Blue values represent positive impact and red values indicate a negative impact.

Figure 2.

External respondents' view of the differential impact of organizational culture factors on charged particle facility operation from external respondents analyzed using the McKinsey 7-S model. Blue values represent positive impact and red values indicate a negative impact.

Which aspects of your institutional or departmental culture have promoted or could promote success of your charged particle facility?

  • Energetic professionals who embrace technological change x4 (Staff)

  • Culture favoring early technology adoption x2 (Skills)

  • Interdisciplinary medical center/University setting x3 (Structure)

  • Culture focusing on quality x2 (Systems)

  • Forward thinking senior leadership supporting project x2 (Style)

  • Support from groups outside the Rad Onc department (Style)

  • Recognition of the potential of new technology (Style)

  • Strong national political connection (Style)

  • Interdisciplinary cooperation to solve technical problems (Staff)

Which aspects of your institutional or departmental culture have hindered or could hinder the success of your charged particle facility?

  • High facility cost x2 (Strategy)

  • Envy from other departments x2 (Style)

  • Reliable development timetable/business model x2 (Strategy)

  • Faculty who are resistant to change x2 (Staff)

  • Physical separation of proton center from photon center (Structure)

  • Different workflow/procedures at proton center (Systems)

  • Emphasis on revenue generation (Strategy)

Which aspects of your facility design have promoted or could promote success of your charged particle facility?

  • Custom building and process design to maximize patient satisfaction, convenience x3

  • Close proximity to photon center x2

  • Designed to optimize work flow x3

  • Latest technology: Rotational gantries, image guidance, spot scanning x3

  • Staff lounge, kitchen, rest area due to long hours

  • Teleconferencing facilities on-site

  • Adequate exam room space to optimize physician work flow

  • Charged particle therapy only offered in order to not compete with photon practices who must refer patients

  • Having mixed protons/carbon particles capacity

  • Not having mixed proton/photon capacity in order not to threaten facilities referring patients

  • Design focused more on patient treatment delivery than on accelerator and beam lines

  • Sufficient ancillary support to allow efficient insurance approval

  • Adequate research support to put every patient on a trial

Which aspects of your facility design have hindered or could hinder the success of your charged particle facility?

  • Not a single site for entire department x3

  • Original design did not include space for accessory storage x2

  • Single modality center; no photons

  • Fixed beams only

  • Prototype, custom built accelerator may have been more problematic than a commercial system

  • Did not include carbon ions

If you were able to redesign your facility or change your organizational culture at this point in time, which area would you focus on for improvement?

  • Change Financial and ownership model x3

  • Locate closer to photon center x2

  • Automated patient setup

  • Direct entry doors

  • Have photon therapy equipment on-site

  • Integrate center with other cancer related services (chemo, photons, labs, radiology, surgery available

  • Eliminate large workroom located away from patient area

  • Larger treatment and control rooms to accommodate technological upgrades

  • Not rely on either passive scattering or scanned proton beams alone

  • Have at least one gantry per facility

  • Use a commercial solution rather than a prototype (i.e. time and cost saved)

  • Hire more experienced personnel early to expedite completion of facility.

  • More space for patients and staff; more storage

Responses from the Mayo Clinic planning group to the questionnaire are shown in the following paragraphs in text, as above. Figure 3 presents a quantitative assessment of which aspects of the values in the 7-S value system appeared as positive and as negative responses most consistently.

Figure 3.

Mayo Clinic respondents' view of the differential impact of organizational culture factors on charged particle facility operation from the Proton Beam Therapy Program analyzed using the McKinsey 7-S model. Blue values represent positive impact and red values indicate a negative impact.

Figure 3.

Mayo Clinic respondents' view of the differential impact of organizational culture factors on charged particle facility operation from the Proton Beam Therapy Program analyzed using the McKinsey 7-S model. Blue values represent positive impact and red values indicate a negative impact.

Which aspects of your institutional or departmental culture have promoted or could promote success of your charged particle facility?

  • Patient focused culture: “Needs of the patient come first” x5 (Style)

  • Integrated Group practice including all specialties x2 (Structure)

  • Culture of efficiency and productivity (Systems)

  • Successful past business model/Non-profit (Strategy)

  • Dedication to excellence in academics and patient care (Skills)

  • Protons and photons available at same site (Structure)

  • Focus on consensus based team decisions x2 (Style)

  • Work ethic promoting clinical productivity (Skills)

  • Particle beam therapy is aligned with Mayo's vision and mission (Style)

  • Willing to aggressively treat cancers to high doses (Staff)

Which aspects of your institutional or departmental culture have hindered or could hinder the success of your charged particle facility?

  • Research productivity seen as not valued x2 (Strategy)

  • Interest in research seen as hurting clinical productivity x3 (Strategy)

  • Poor institutional understanding of the role of radiation therapy (Strategy)

  • Old physical plant and facilities not allowing growth of practice (Strategy)

  • Lack of mentoring experience to help young faculty grow (Style)

  • Institutional inertia (Strategy)

  • Lack of clear communications between levels of staff (Systems)

  • Overspecialization and having a silo mentality (Staff)

  • Jealousy over the resources devoted to the proton center (Strategy)

  • Emphasis on physician autonomy (Systems)

Which aspects of your facility design have promoted or could promote success of your charged particle facility?

  • Close proximity to photon center x4

  • Part of a Multidisciplinary medical center x3

  • Efficient practice work flow

  • Information systems that optimize workflow

  • Space for expansion

  • Convenient Parking for staff/patients

  • Ease of staff/patient movement between photon and proton practices

  • Slow, deliberate approach to facility design

Which aspects of your facility design have hindered or could hinder the success of your charged particle facility?

  • Not a single site for entire department x5

  • Pencil beam scanning alone is a risk x2

  • Need to include all members of care team in design/implementation

  • Not enough physicists

  • Cost model for proton therapy too high

  • Transparency in communication from dept. leaders

  • Governance/Division of resources between departments

If you were able to redesign your facility or change your organizational culture at this point in time, which area would you focus on for improvement?

  • More focus on academics

  • Quicker implementation of new technology

  • Reinvigoration of an equal balance of clinical practice, research, and education in the workplace

  • Atmosphere in department that supports adequate mentorship for new faculty

  • Include representatives from all levels in the care team in decisions

  • Engage stakeholders by disease site to embrace new technology of protons

  • Optimize workflow for patient positioning/pre-RT image review

  • Integration of facility with photon practice

  • Change culture to reward desired behavior and punish undesired behavior

Discussion

The academic study of societal culture by anthropologists began in the late 19th century. By the 1970's, business researchers began to increasingly think of organizational culture in a manner analogous to societal culture. Organizational culture gained significant importance in management theory during the 1980's when Japanese companies began to challenge Western corporations for market dominance in a number of areas. Since originating from sociological and anthropological theory, a divergent spectrum of theoretical models for organizational culture have been proposed [3]. Although there is widespread agreement on the potential impact of organizational culture on behavior and actions taken by groups, there is no exact definition of what constitutes “organizational culture.” Most scholars would view organizational culture as a “system of shared meaning” [4]. Schein has proposed defining organizational culture as a “pattern of shared basic assumptions learned by a group… to be taught to new members as the correct way to perceive, think, and feel” [5].

Numerous theoretical models exist for analyzing organizational structure in relationship to culture. For a value centric organization, McKinsey's 7-S model is well suited to use to analyze organizational culture (Figure 1). In this well-known model organizational values are viewed as being determined by a matrix of 6 cultural factors, 4 peripheral “soft” variables (Skill, Staff, Systems and Rrocedures, and Style of Management) relating to attitudes and practices and 2 peripheral “hard” variables (Strategy and Structure) relating to how resources are tangibly used to meet organizational goals. “Shared values,” the 7th “S”, represents the final “soft” variable at the center of the matrix [6, 7].

The Mayo Clinic consists of 3 large, geographically separated group medical practices, operating in Jacksonville, FL, Rochester, MN, and Phoenix, AZ. Together, these 3 entities employ over 50,000 people and 3,700 physicians and scientists, as well as 3,200 students and physicians in training. Allied with the Mayo Clinic are 20 community hospitals and over 100 clinics in the Mayo Clinic Health system, a community-based healthcare network in the American Midwest [8]. Mayo Clinic views itself as an organization focused on shared values in which strategic, operational, and day-to-day planning is performed in the context of meeting its primary value, “the needs of the patient come first,” in caring for patients.

The Mayo Clinic Proton Beam Therapy Program will consist of 2 facilities, each approximately 100,000 square feet in size, located at the group medical practices in Rochester, MN and Phoenix, AZ. Each center will have 4 treatment rooms with rotational half-gantry systems capable of delivering a scanning beam of proton radiation with sub-millimeter accuracy to treat a variety of adult and pediatric cancers. Proton beam radiation therapy will be considered as one choice of many treatment options for cancer within the context of the group practice. The 2 centers will be operated as a single administrative unit, with nearly identical equipment, system and procedures, quality assurance, research infrastructure, and quality assurance at both sites. Staff size will more than double in the Radiation Oncology practices in Minnesota and Arizona, presenting a challenge in cultural stability as the new employees are educated in and embrace the Mayo Model of Care. Radiation Oncologists will be expected to use either protons or photons, or other modalities, within their disease site of specialty, depending on the medical needs of the patient and the dosimetric advantages or disadvantages of each modality. Physicians are salaried, without a productivity target, so there is no direct incentive to utilize one modality over another. Patients seen at the Mayo group practice in Jacksonville, FL will be referred to the existing University of Florida Proton Therapy Institute.

The merger of 2 organizational cultures, or subcultures in the case of the Rochester and Arizona facilities, is a common problem following acquisitions and mergers between 2 entities that may have very different values and assumptions. Similarly, joint ventures between 2 distinct organizations may also present cultural challenges when working together on a specific project that does not require merger of the organizations into a single entity. Schein has noted that the problems posed by such mergers can be alleviated in part by an open leadership style that facilitates communication at all levels, promoting leaders with innate cultural sensitivity, joint training between groups, and a regular process review before and during project implementation [9].

In summary, the design of the Mayo Clinic Proton Beam Therapy program will require 2 major considerations with respect to culture:

  1. 1.

    The facility design and organizational structure must promote Mayo's primary value and its integration into the group practice.

  2. 2.

    The organizational structure will foster further cultural convergence between the existing radiation oncology practices in Rochester and Arizona.

External respondents to the survey stated that the elements of their organizational culture that made their facilities successful were primarily related to having dynamic professionals who could see the value of new technology, and leadership able to think strategically about a full range of cancer care solutions. In terms of the McKinsey 7-S model, the cultural areas where positive decisions drove success were in style and. Respondents felt that negative decisions related to locating the facility as a stand-alone center isolated from the other half of the department and from a multi-specialty practice or due to poor business planning or financial model, strategy characteristics in the McKinsey model, had the greatest potential for hindering success in the particle center.

Design aspects critical for successes were again focused on integration of the facility into the existing photon and multi-specialty academic medical practice. Workflow considerations were felt to be a more critical aspect in determining a facility layout than engineering for the accelerator and beam line. A focus on technological excellence and quality were felt to be important to a successful facility.

For external respondents that listed aspects of their facility that they would change, responses centered on altering their ownership or financial model, relocating their facility to a site allowing more integration with their photon practice or parent medical center, and a variety of technical aspects relating to optimizing workflow.

The introduction of charged particle programs was felt to have a positive impact on departmental culture through improving morale, increasing willingness to embrace technological change, and through national recognition of the department's work. Negative changes related to external criticisms regarding increasing medical costs and in the potential of the proton practice to divide existing departments into silos of employees devoted to different modalities.

For respondents in the Mayo Clinic planning group, the survey revealed several areas of mutual agreement and a division in opinion relating to the role of research in the facility, with a minority of clinicians expressing concerns that research operations would negatively impact clinical workflow. Many respondents felt that Mayo's primary value would directly play a role in promoting success through a common bond through a focus on patient outcomes. Similarly, the Mayo respondents felt the existing multi-specialty nature of the group practice would facilitate integration of the proton therapy center into the existing oncology practice.

Concerns that were identified in the external survey and deemed most critical to the success of the Mayo program through support of a unified practice culture were integration of the proton and photon treatment centers at a single physical site and a practice and workflow structure that discouraged the formation of silos of differening specialties. These concerns are similar to the problems that prompted the Mayo Brothers to construct the first group medical practice within a single building. The following actions are being taken to address these concerns:

The proton facilities at both sites are being constructed as close to the existing photon practices as is physically possible in order to foster development of a shared organizational culture. External and internal respondents to the survey strongly emphasized the need for physical integration of the proton center with the department's photon practice as a key driver in avoiding creation of worksite subcultures.

Common work practices, workflow, quality assurance processes, and information management systems are being developed and standardized at all eight photon and proton practice sites in the Mayo Clinic system.

Clinical treatment protocols and research protocols for both photon and proton practices are being developed by standing, multi-site disease specific task groups that include representation from all practice sites.

A substantial investment in research infrastructure and personnel has been made to prevent a negative impact on the clinical workflow. A plan will be developed to monitor resource utilization over time as the practice evolves.

The design changes involving workflow and clinical protocols are intended to nurture a common culture amongst the therapists and allied health staff, who will be involved in both photon and proton treatments, and for dosimetrists and physicists, although their technological focus will require a greater degree of specialization. In contrast to external institutions, Mayo respondents did not identify recruitment and development of staff as a priority as external responders did, although this has historically not been an issue at Mayo Clinic.

Conclusion

Successful operation of a proton radiation therapy center is a difficult task, requiring mastery of sophisticated treatment delivery systems and oncological practice in addition to successfully resolving the management and organizational challenges associated with running a facility of such size and complexity. Additionally, the structure and culture of such facilities may impact how organizations interact with patients, the public, and medical groups external to the proton therapy practice. The results of this survey would suggest that careful attention to recruitment or development of staff that embrace technological change with the necessary technical skills to allow them confidently adopt proton radiation therapy are important components in designing a proton radiation therapy program. The survey also suggests that strategic decisions regarding resources and business model alignment may most negatively impact departmental culture and perceptions of success.

ADDITIONAL INFORMATION AND DECLARATIONS

Conflicts of Interest: The authors have no conflicts of interest to disclose.

Portions of this work were submitted as a thesis in partial fulfillment of the requirements for the Postgraduate Diploma in Organizational Leadership at the Saïd Business School, Oxford University, Oxford, UK, January 14, 2011. This work was presented in abstract form at the 50th Meeting of the Particle Therapy Cooperative Group in Philadelphia, May 11–13, 2011.

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