Originally published in Becker’s Hospital Review

By Kenneth T. Hertz

Many have likely heard about hospital deserts, those patches of mostly rural America where the last hospital has closed, forcing ambulances and patients to travel a hundred miles or more for emergency or routine care.

It’s a growing crisis—since 2010, nearly 90 rural hospitals have shut their doors, with some unknown hundreds headed in that direction.

This phenomenon doesn’t happen by accident. Demographics, specifically a declining patient base that is disproportionately elderly and low-income and inadequate Medicaid and Medicare reimbursement policies are common catalysts. Often, it’s not just one of these factors but a little of each that contribute to the outcome.

But the painful truth is that how a hospital reacts before these kinds of financial maladies strike is often the difference between survival and death. Not every downward slide has to be terminal. Solutions do exist to stanch the bleeding.

So what can at-risk hospitals do to ensure that the space they occupy today doesn’t become a desert tomorrow? Not surprisingly it all starts with the fundamentals.

Bad management can sink even the strongest of businesses; good management can keep an otherwise leaky ship floating for longer than anyone thought possible. And nowhere are these strengths and faults more obvious than when someone new joins the company.

Hospitals are buying physician-owned practices at a record clip. With those acquisitions comes an ever more pressing need to align the mission and vision of both physicians and the hospitals absorbing them.

Having spent 25 years talking to rooms full of doctors, I know that most of the time their eyes start to roll the minute they hear the words “mission” or “vision.” I understand why they feel that way—their job is to provide care, not to create a culture. I also know that in survey after survey, when asked to identify the two traits they look for in leadership, those same doctors always identify good communication and listening. Two traits that are critical for shaping a mission and sharing a vision.

I also understand how this same stubbornness expresses itself in administrators. I can recall the hospital executive in the Midwest who adamantly refused to place a physician on his board just because his father had refused to do so when he had the job before him. Administrators view these purchases in overly financial terms—they bought the practice, after all, in order to help, in some cases help save, their hospitals. But doctors aren’t parts on a shelf at Autozone. And treating them that way is bound to lead to even more problems.

Let’s say a cardiology practice purchased by a hospital system is doing well. To the hospital, this success may suggest that another cardiology practice would be an even better purchase. To the original practice, it may be viewed as a betrayal.

It sounds hokey, but the keys to keeping the doors open are the same keys that help already prospering hospitals thrive. Fostering open, transparent and honest communication; developing a culture of respectful listening; these are the building blocks of cultural alignment.

The best hospital systems in the country have the luxury of creating new leadership roles designed to solve the most basic, yet persistent, problems faced by practitioners. Struggling hospitals don’t have that same luxury. Which is why a focus on culture needs to come first.

What does that look like on the ground level? It means a physician can’t sell her practice on a Friday and come to work that next Monday—onboarding can’t be an afterthought, it must lead the conversation. It means administrators who don’t schedule meetings at ten or two, in the middle of a physician’s day. It means executives who make the equivalent of house calls, checking in on individual practitioners and practices instead of waiting for someone else to come to their faraway office with a problem.

Struggling hospitals and hospital systems have good reason to seek out physician-owned practices or other additions that may improve the care they can offer and improve their odds of survival. But the focus can’t fall solely on the bottom line.

Hospitals and administrators will always face challenges that are beyond their control. That’s why it’s so important to focus instead on what can be controlled.

That starts first with an alignment in vision, mission, values and goals, not just for the physicians starting their first day at a new job, but for every stakeholder in the system. Because if administrators don’t account for culture, the fixes meant to help a struggling hospital may instead hasten its demise.

Kenneth T. Hertz, FACMPE, is a principal consultant at Medical Group Management Association (MGMA), in Englewood, Colo., and has held leadership positions in small and large healthcare organizations in primary care, multispecialty care and large integrated systems throughout the country.