(Author’s note:  SETMA is often asked, “How did you build this organization?”  In an attempt to answer that question, we have begun writing a Developmental History of SETMA.  This differs from a simply Chronological History as it attempt to understand the dynamic of the processes which resulted in SETMA.  Some of these processes were intentional but most were serendipitous.  As we develop this history, we hope to explain to ourselves and to others how this process can be duplicated elsewhere.)

In April, 1995, four physicians in Beaumont, Texas began discussing the formation of a group practice.  One of the four had a fifth physician who worked for him.  These physicians had individually been in the private practice of either family medicine or internal medicine from ten to twenty years.  On Tuesday, August 1, 1995, SETMA opened the doors on this new adventure. 

The primary motive was to respond to the challenges of managed care which we all saw as a challenge to our future.  As the pressures of managed care increased, we pushed back.  We resented the need to hire people for dealing with referrals and pre-authorizations.  We saw managed care as an intrusion upon the way we had practiced medicine all of our careers. 

While we were judicious in our utilization of studies, procedures, tests, etc., we still saw the business-side of our practice as a function of doing more tests, more procedures, more studies, etc.  We measured and reported provider productivity and from the first day, we produced a daily cash flow report which told us what we owed, when we owed it, what our bank balances were, how much money we needed to collect every day in order to sustain the practice, what each provider produced and collected, etc.  This focus on measuring, auditing, tracking and reporting would become critical to our future.  But gradually, we began to see that what we were measuring, tracking and following were not the important issues for our future or for the future of medicine.

Team Building

Before SETMA understood that Twenty-First Century medicine could not be practiced with pencil and paper (19th Century Medical Record Methodology) or with Dictation and Transcription (20th Century Medical Record Methodology), both of which drove us to Electronic Medical Records in 1998, SETMA understood that the demands of 21st Century medicine would require a team approach to healthcare delivery.  All of the team building concepts in this chapter about SETMA’s beginnings were enunciated in 1995 and 1996.  They have been repeated and refined but they have been part of the organizational spirit of STEMA from the beginning.

Formed by four partners and from five practices, the new organization was made up of employees who had loyalties to different employers, each of whom had different styles of practice and all of which had worked independently for years.  Creating a team out of this group would be challenging.  Some medical records were done by handwriting and others were done by dictation and transcription.  Some records were organized alphabetically and others numerically.  All practices had laboratory equipment, none of which interacted with each other.  One practice had sacks of laboratory test results which had never been filed and another had accordion files with thousands of pages of lab results which had never been placed in the patients’ charts.  It would take over ten thousand dollars of paper products just to convert the five practices to a common paper filing system.¹

One provider mentioned electronic medical records, but none of us knew what that looked like.  We needed a team but we had no tools with which to build a team.  Nevertheless, team building was the most important part of the early days of SETMA. In reality, our efforts at team building were directed toward making our “business” run better, but we shortly would discover that without that team spirit and effort, we could not produce the results we desired in the delivery of excellent healthcare. We discovered that 21st Century medicine could not be performed excellently without all members of our practice working together to care for patients.  Roles and duties were going to have to change.  Each member of that team would need to gain new respect and appreciation for the contribution of every other member of the team.

Team Building and Discouragements

As if our differences were not enough of a barrier to the success of the new enterprise, only four months after the founding of SETMA, on December 4, 1995, one of our partners was injured in an automobile-pedestrian accident which resulted in multiple fractures to both lower extremities. This was the first major challenge to SETMA’s success; and, it was the first of what would be many challenges to our commitment to a team-based practice.  For the eight weeks our colleague was out, I would be in my office one day and in his office the next.  No patient’s needs were unmet and all of our partner’s needs were fulfilled.  It was a strain, physically, financially and emotionally but we survived it, as did he, and it made us stronger.

Fourteen months after we started SETMA, one of the founding partners filed an injunction against the practice on a Wednesday afternoon.  The papers were served after five in the afternoon, making it impossible for us to deal with until the next morning.  However, by 10 AM the next morning, the injunction was removed and a negotiated settlement was reach. The partner was gone and SETMA was stable.  His departure was disappointing and particularly the way in which it was done, but it did not stop our efforts to build a team.  From the outside, it looked like the practice was unstable, but from the inside, it was prospering with excitement, energy and commitment.

Eight months later, a provider left STEMA involuntarily.  Soon, we became aware that that provider had filed a Qui tam law suit against SETMA alleging extensive fraud and criminal conduct by the founding partners of SETMA.²   While there was no substance to the accusation, a fact which was determined by the Federal Justice Department, the investigation dragged on for five years.  If there were any thought on our part of “giving up” on team building, this would have done it, but it did not. 

And, as with any new enterprise, there were financial pressures. One of the reasons for having principles and commitments is that they guide you through difficulties. Without them, compromise and mistakes will occur.  SETMA was founded on principles of business-decision making and they kept us from serious mistakes.  There were three principles:  ethics, equity, eternity. 

• All decisions had to be legal.  We referred to that as ethics.
• All decisions had to be fair.  We referred to that as equitable.  Decisions had to be good for bother parties rather than being a zero-sum game with winners and losers. 
• All decisions had to be moral or right.  We refer to that as being eternally significant.³ 

Early on, SETMA’s principles were put to the test. In January, 1996, we arrived at the point that we wanted to provide health insurance for our employees.  After applications and interviews were done, the insurance agent told me that there was one employee whose health history was such that if we insured her our annual premium would be $10,000 higher than it would be if she declined the insurance or if we dismissed her.  Intuitively, the right decision was obvious, but with defined principles to follow, this was also an easy decision to make. I asked the agent, “Is there any legal way that I could ask her to decline the insurance?”  He said that anything we said would be a violation of the law.  I then said, “She is a faithful employee and even after knowing that once all five practices were together she will probably not have a job, she stayed with me.  Do you think it would be fair, to dismiss her over the cost of insurance?”  He agreed that he thought it would not be.  Finally, I said, “Do you think that in the grand scheme of things that this lady came to my practice without insurance which she desperately needed and the in the providence of God that her needs were going to be met by our insurance?”  He agreed that that was possible.

I told him, “Then we will insure her.”   This was at a time when $10,000 was a serious expenditure for SETMA.  He marveled. When I called her to tell her she would have insurance, she wept.  In June, when our new office was available, we kept her on, working at a job beneath her training, but paying her professional salary.  Almost one year later, we discovered that the person who was performing the professional services for which this lady was trained was incompetent.  Without any disruption to care, the lady with the insurance problems was able to move into the job for which she was trained.  We had blessed her and now she was blessing us.  SETMA’s history is filled with stories like this.

The principles upon which we founded SETMA  and our responses to these pressures contributed to our building a team.  We began to know that we could not only survive pressures but we could surmount them and succeed in the face of them.   And, we could do that internally with ourselves and externally with others with whom we would work.  We began to learn that team building not only involved how we related to one anther but also to how we related to others outside of SETMA, 

Team Building through Communication

It took until June 17, 1996, for all of SETMA to be moved into a single location from the five offices which the merging practices had occupied.  Upon moving into one location, our efforts at team building accelerated and we began publishing “The SETMA Sentinel” which was “irregularly and irreverently” published.  The Sentinel was  an in-house publication for the building of team spirit and for the making of one office out of five different medical practices.  It evolved over several years to be a means of communicating the core values, the philosophy, the growth, the vision and the mission of SETMA.

The Sentinel was also used to develop SETMA into a “learning organization” and into a team which creates opportunities for growth and development of individuals.  Perhaps the intent of The Sentinel was best expressed by a statement from Peter Senge’s The Fifth Discipline:⁴

Max de Pree, retired CEO of Herman Miller, speaks of a ‘covenant’ between organization and individual, in contrast to the traditional ‘contract’ (‘an honest day’s pay in exchange for an honest day’s work’).  ‘Contracts,’ says De Pree, ‘are a small part of a relationship.  A complete relationship needs a covenant€¦a covenantal relationship rests on a shared commitment to ideas, to issues, to values, to goals, and to management processes€¦Covenantal relationships reflect unity and grace and poise.  They are expressions of the sacred nature of relationships.’  (p. 145)

SETMA’s goal was and is for everyone in SETMA to rediscover the sacred in business relationships based on mutual respect, common goals and a commitment to common values.  The Sentinel’s goal was to employ humor, inspiration, information and education as a means to this end.  Not only did the Sentinel record and preserve SETMA’s history; it helped make SETMA’s history.

More important, however, than the written communication, was the living dialogue that formed SSETMA.  At its formation, the community believed that two of the partners could not work together.  They seemed to be too different in their approaches to live and to medicine.  Informally, and without an intentional plan, these two partners began to spend hours and hours talking after clinic hours.  In October, 1997, the two attend the Medical Group Management Association meeting in Washington, D.C.  In a pre-conference Strategic-Planning seminar, they realized they had the same goals and while their methods and manner were different, they had the same goals, passions and resolve.  This was a great contribution to the building of the SETMA team.

Team Building  - Risk Taking

Success can only take place in the face of the potential of failure, i.e., risk taking.  In September, 1995, we addressed team building and risk taking with President Teddy Roosevelt’s 1887 observation about risk:

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better.  The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, and comes short again and again, because there is no effort without error and shortcoming; but who does actually try to do the deeds; who knows the great enthusiasms, the great devotions, who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who know neither victory nor defeat.”⁵

SETMA’s formation did risk failure, but we were determined that if we failed, it would  not be because we did not “try.”  If we failed, it would not be because we did not set the standard very high and try to scale the wall to reach the standard!  If we failed, it would not be because we sat on the sidelines and envied what others were achieving.  In the sixties, there was a wonderful song entitled, “To Dream the Impossible Dream.”  We were willing to dream what at the time seemed impossible.  And, we realized that it was possible not to be able to achieve SETMA’s goals, which was:

• To create a clinic where our patients’ Healthcare is the Only Care
• To fulfill SETMA’s private motto of “Doing Good While We Do Well”
• To answer every call every day from every patient
• To compassionately care for those for whom no one else cared
• To honorably and honestly deal with every issue which came before SETMA
• To review every laboratory and x-ray report the day that it is reported
• To deal courteously and kindly with discourteous and unkind people
• To instill dignity and respect into every person who contacts SETMA whether in person or on the phone
• To improve the health of our patients by expanding the services which are available to them
• To set the standard for quality health care in the Golden Triangle

SETMA took the risk and succeeded.  In the process of building a team, we succeeded.  It is not surprising that team building is both a process and an outcome of risk taking.

Team Building as a Family

The SETMA family did not result from our having the same mother and father, but nevertheless, we became a family.  We were of different backgrounds, nationalities, faiths, ethnicities, genders, and ages, but we became a family.  We enjoyed watching each member of the SETMA family grow and mature..  Today, we continue still delight in seeing what each colleague can become individually and what we all can become collectively.  As the SETMA team emerged, it was a delight.  And, as a family-team, we all became protective of each other.  When one hurt, we all hurt; when one rejoiced, we all rejoiced.  As pointed out above, there were disappointments.  There were those who did not want to be part of SETMA’s team or family.  Some left quietly; others used their relationship with SETMA to build other businesses before leaving.  Over time, we discovered that everyone that left, only strengthened SETMA in leaving. 

We learned that as a family:

• We were more interested in solutions than in blame.  When we discovered a problem, or when we experienced a problem, our first thought was, “How can I solve this problem,” rather than, “Whose fault is this?”  A family wants everyone to succeed.  Early in SETMA a memo stated, “You will never be as successful as when you help someone else fulfill their potential while you are succeeding yourself.”  Blame is cheap and therefore worthless; solutions are expensive, and therefore extremely valuable!
• We wanted to support others when they were having a “bad hair day,” or when they have a special, personal need.  We wanted to support them with enthusiasm!  We wanted support them with an eye to making their load lighter, even if it meant a brief increase in our load!  In the long run, this approach to a team spirit will make us all winners..
• We wanted others, especially the guests of our family - who are our patients - to think well of our family and to speak well of our family.  It’s so much more encouraging to our guests when they hear us say, “Can you believe how busy our front office is, and yet they still get the job done.  I’m sorry for your delay, but they are a great team!”  Rather than, “That dumb front office lost your chart!”  When we speak well of other members of our family, we really speak well of ourselves.  When we speak badly of them, our guests associate that negative attitude with us as well.
• We wanted our guests to have the best possible experience with our family.  Therefore, the first contact with us had to be positive.  The receptionists had to be friendly, attentive and helpful.  No one could be ignored in our waiting room.  The file clerks needed to reflect an attitude of wanting to help the entire team function well.  They needed to speak kindly to one another, and they needed to do their best to facilitate our guests having a good experience while in SETMA’s office.  We wanted our guest to look into our front office, and say, “This is the kind of place I want to come to.”

Team Building Requires Leaders

The team leaders of SETMA - some people call them physicians or health-care providers - but we called them what they are, team leaders - needed to be leaders especially when things are going badly.  Rather than succumb to frustration and irritation, team leaders needed to encourage those around them to avoid:

• Anger - there is not a more destructive emotion in a family, in that it reflects a low regard for the person-hood of the one toward whom anger is expressed.
• Impatience - this is a condescending and demeaning attitude, which suggests that the one toward whom impatience is being expressed is less important than the one who is impatient.  The truth is that everyone in our family is important and no one is unimportant.  If they a person are not important, then they don’t need to be here.  If they are here, they need to be treated with the dignity and appreciation which their importance requires.
• Rudeness - a rude and thoughtless person reflects their own poor character, not anything about the one toward whom they are rude.  Rudeness is unthinkable from anyone, but especially from a leader.  On the anniversary of his hundredth birthday, friends and acquaintances of Albert Einstein were asked to remember him.  The most common memory was the he was KIND.  Rudeness and kindness are mutually exclusive.
• Selfishness - nothing is more unattractive in a family than self-centeredness, which is reflected in ignoring the needs of others in order to “get what you want.”  Leadership means that you put aside your needs for the benefit of others.  Physicians, as team leaders, look to the meeting of the needs of those who support them, even before team leaders' needs are met.  This often means neglecting the leader’s business, interests, pastimes and friends until the needs of other team members are met, such as getting to lunch on time at noon or getting home on time in the evening.  A leader also puts the interests of his or her guests above his own, which means delaying other activities and treating his or her guests with preferential attention.

A leader is one who keeps his or her cool when everyone else is loosing theirs.  A leader is not one who occupies a “position,” but one who overcomes pressure, rises above it and shows others how to do the same.  A leader is one whom others can “lean on” when they are down, discouraged or disappointed.  Every team member, no matter what their position, has the potential of being a leader.  And, leadership is what a company looks for when rewarding service.

A team cannot exist without leaders, but leaders are not commanders; they are colleagues, examples and they are those who see something which needs to be done and they do it. By example, they lead members of their team to become leaders themselves.