Dr. Akram Boutros finds the Rx for MetroHealth is engaging in the culture

When he joined The MetroHealth System as president and CEO, Dr. Akram Boutros, FACHE, needed to know if employees and management knew what the organization’s mission and vision statements were.

After asking those that he met, he determined it was a lost cause. No one could recite the few paragraphs that comprised either of the guiding proclamations.

“I asked about 50 people to describe in their own words what the MetroHealth mission and vision was,” he says. “I got probably 60 different answers from 50 different people.”

That situation became a critical issue. Without knowing where they were going, the organization’s 6,000-plus employees were unable to reach any goals. Boutros knew employee engagement was essential if he was going to turn the operation around, both to stop the bleeding and to make over the aging main campus, a project of such scale that it had to be viewed as a complete transformation of all things MetroHealth.

The problem was quite clear to Boutros.

“There is no engagement in the campus transformation without engaging the entire MetroHealth transformation,” he says.

When he took the helm on June 1, 2013, Boutros discovered a first quarter deficit of $6.5 million. Under his leadership, he helped MetroHealth finish 2013 with $18.9 million in net operating income. Several factors contributed to the financial improvement, including a reduction in the cost per patient and an experimental Medicaid waiver program that expanded insurance coverage to nearly 30,000 people in Cuyahoga County.

As far as sprucing up the vintage main campus, discussions took place as early as 2010, but it took last year’s polar vortex to illustrate how fragile the facility had become. Pipes froze and burst in subzero temperatures and patient rooms flooded.

Boutros announced the $400 million transformation plan calling for about 75 percent of the main campus to be rebuilt or renovated, with work to start in 2016 and end in 2020.

Here’s how Boutros is taking a holistic approach to turning around the 178-year-old institution, which saw 2013 annual revenue of $855 million.

First step: start writing

Developing the mission, vision and values statement became Boutros’s key issue and would be the first step to drive the transformation.

“That’s one of those critical steps that without it, you can’t engage the management, the staff, the community, your patients, your doctors,” he says. “They have to know what they’re doing.”

MetroHealth System’s
new statements

Leading the way to a healthier you and a healthier community through service, teaching, discovery and teamwork.

MetroHealth will be the most admired public health system in the nation, renowned for our innovation, outcomes, service and financial strength.

Service to others
Inclusion and diversity
Quest for excellence

It was time for a cultural makeover. Management turnover and significant financial cuts made in 2008 to balance the budget contributed to low employee morale at the county-owned MetroHealth.

The first thing Boutros undertook was a back-to-basics review, revisiting the mission, vision and values. Even before he came to MetroHealth, he told the board of directors that during his first week, he would hold weekly two-hour mission, vision and values meetings with his strategy committee for the next six weeks.

“We needed to be absolutely clear about what our purpose for existence was, what we saw ourselves becoming and how we were going to get there,” he says.

The strategy team consisted of representatives from the board, senior management, the medical staff and even competitors.

“We had a pediatrician from University Hospital on the committee,” he says.

Other members included a union representative and the head of the nursing senate.

Starting with a blank slate, the committee encouraged participation from all employees and constituents. While the discussions took place, a graphic recorder turned the complex dialogues into instant visuals. These were then posted in a hallway to be shared with employees. Notes and discussion summaries were also emailed each week to employees and constituents.

“We had more than a thousand submissions, comments, changes and things for consideration,” Boutros says, “and I had lied to the board — I told them it would take six meetings for us to do it; it took five.

“By having such an inclusive process, not a single person in this organization felt strongly against us,” he says. “We were very passionate about our mission, vision and values.”

Well-known for his exuberant persona that values employee feedback and interaction, Boutros is also famous for starting at 5 a.m. and working sometimes until 11 p.m., greeting employees enthusiastically as he walks the hallways and asking if they need anything.

But even with that familiarity, he made sure he distanced himself from the strategy discussion and says the mission, vision and values statements had very little to do with what he saw for the organization, but more of what the committee collectively saw for MetroHealth.

“My job was as a facilitator, so I didn’t participate,” he says. “I in no way had an opinion about the mission, vision or values.”

When the person in authority is genuinely interested in learning from somebody, there’s no higher amount of respect they can show them, Boutros says.

“Each individual interaction confirmed what they were hoping to have,”  he says.

The focus became sharp as a needle: “Our mission is why we exist, our vision is where we are going, and our values are how we are going to get there,” Boutros says.

“If we want to change how health care gets delivered in the U.S., the only way we’re going to do that is by influencing others. That’s why our vision is to become the most admired public health system in the nation, so we can influence others to follow the good works we’ve done.”

Decide where best to start

Putting the mission, vision and values statements to work must start at the most opportune level. Many organizations follow the concept that leading by example, from the top executive down, is the proper method to institute a cultural makeover.

Boutros, however, disagrees with his colleagues who follow that process. He starts the makeover from the employee level. This is where faith in the leadership is important.

“You cannot follow someone you don’t trust,” he says. “The employees who provide direct care are the most important people in this hospital, much more important than me and my management team. They’re the people who actually make a difference.”

To experience this firsthand, Boutros on his first day dressed as a transporter and whisked patients throughout the hospital in wheelchairs and gurneys. It gave him an important view of the entire operation.

“It demonstrated a respect for every part of our organization and everyone’s contribution. We all have a role to play, and we don’t succeed if each one of us is not playing that role,” he says.

By making himself available to employees, meeting and talking with them and answering every email, he has earned the trust of his team.

“It’s a level of comfort and partnership that exists honestly between me and the individual staff member,” he says.

Developing that comfort and partnership goes hand-in-hand with developing a culture of safety to think freely, Boutros says. For instance, he feels it is important to demonstrate that it’s OK to make a mistake and fail for the right reasons — on the operations side, that is.

“The business side of the operations, and the way we deliver care, we can change all of that. The medicine that we use to take care of somebody we can’t change,” he says. “That needs to be scientifically based, and based on how we’ve done things over time.”

Success is great but failure can also be very good, Boutros says, because it offers a second chance to convert failure into a positive.

“Convert failure into learning,” he says. “People have tested my veracity to that. They have done it in multiple ways and are always pleasantly surprised when we celebrate the learning as much as we celebrate their successes. That’s how we’re creating this culture of safety. For the right reason, you can challenge anybody.

“The culture certainly is working because the idea of us making this financial, clinical and operational transformation in a short period of time makes people think there’s wizardry involved. The only wizardry involved is having 6,000-plus people working on the same thing, rowing in the same direction.”

Management focus: teamwork

Boutros says by their very nature, managers tend to be personally focused overachievers, not only in health care but in almost every corporation in America. The challenge therefore is to bring a teamwork focus into the management, removing the spotlight from individual contributions and putting it on team contributions.


To offset the self-centeredness and to build a sense of teamwork, Boutros met with senior leadership during his first year and developed collective goals.

“Today, 70 percent of their goals are organizational goals and only 30 percent of their goals are personal,” he says. “It continues to be not about who scores the baskets but what the final score is.”

Speaking of making baskets, Boutros uses the example of a hometown sports hero to illustrate his stress on teamwork.

“I admire LeBron James because of that,” Boutros says. “He may be the most capable player on the team, but he understands that if everyone on his team performs to his very best, then they’re going to win. So that’s the same things we try to do here. Just because you can doesn’t mean you should. Sometimes it means letting somebody else take the lead and move with a project, and in total we get the successes.”

Middle management, however, offers the most challenges, since organizations have hired middle managers to do what they’re told.

“They are inherently risk-averse people,” Boutros says.

To help change that frame of mind, MetroHealth launched programs to change middle managers’ perception and skill sets. A chief experience officer was hired and a patient experience office was launched. Boutros, who admits his penchant for metrics, took the approach to focus on patient outcomes, not satisfaction.

“Our measuring stick was, ‘Were patients better off than when they came in?’ It wasn’t, ‘Were you happy with our services?’ So we needed to change that,” he says.

Every employee, manager, board member and physician goes through patient experience training their first year.

One other program offers the TeamSTEPPS system through the Agency for Healthcare Research and Quality to not only improve patient safety but to improve communication and teamwork skills.

It caught on so well that MetroHealth went from being a hospital just learning about TeamSTEPPS to becoming one of eight regional training centers in record time.

“We are giving employees training, we’re giving them opportunities to prove themselves, and, frankly, people are also selecting to stay in or go out,” Boutros says. “For example, in the three months that we’ve had values testing for our new employees, we’ve reduced our 30-day attrition rate from 6 percent to 0 percent and our three-month rate from 12 percent to 2 percent.

“Some people have left the organization saying, ‘This is too much stress for me. I just want to be told what to do and do it.’ That’s not accountability for me; that’s not exercising leadership. If you don’t want to exercise leadership, this is the wrong place for you.”

Evolve your external image

As the internal perception of MetroHealth improved, Boutros used the same plan to improve the external perception.

“We used the same candor, transparency and passion to transform the internal stakeholders as we are doing with external stakeholders,” he says. “There’s nothing you can’t ask us that we won’t answer. We’re your hospital. So whatever you need, whatever you want, we’re here for you and we will answer any questions you have.”

Boutros made it a priority to engage with the Cuyahoga County Council, the county executive, the mayor, Cleveland City Council and with competitors — Cleveland Clinic and University Hospitals.

The latter two Boutros prefers to call collaborators, not competitors.

“We want to work with everybody, and we think the MetroHealth mission and our progress wins the day,” he says. “It may take a little bit longer to achieve than a sales job, but it has more staying power.

“We have a very different mission, and we have a very different focus to deliver that mission. We don’t want to rely on high-cost facilities to provide the best level of care. We want to be able to provide services at your convenience in your neighborhood on your own terms. We want to be able to engage patients, not for the short-term treatment but for life sustaining wellness. It’s a very different model.

“It’s like saying that bicycles, cars and boats are all transportation. They are, but I think they just have different customers and different ways of approaching transportation,” Boutros says.


  • Develop concise mission, vision and values statements.
  • Start your transformation at the level that makes the most sense.
  • Focus on teamwork and improving your overall image.

The Boutros FileDr-Boutros-490

Name: Akram Boutros, M.D., FACHE
Title: President and CEO
Organization: The MetroHealth System

Born: Cairo, Egypt. I came to the U.S. when I was 12 ½, and lived in Queens, New York.

Education: State University of New York Health Science Center at Brooklyn, Harvard Business School’s Advanced Management Program, St. John’s University.

What was your first job, and what did you learn from it?

I worked for my dad in the jewelry business. I learned that it’s not good to work with family. You spend way too much time with each other. I also learned early on business skills that I would never have had otherwise.

The first outside job I had was a paperboy. That also led to a life-altering event because I was heading down the wrong path in life. I was hit by a truck. I spent a long time in the hospital recuperating and that kind of altered my life. I decided I had to do something that mattered. The accident put me on track to become a doctor.

Who do you admire in business?

The late Steve Jobs is somebody I admire because he believed stronger, longer and more passionately in what Apple was doing than anybody else. Resilience, tenacity and leadership are really important. He also believed in being transformational, doing something that impacts the world. It wasn’t purely the money, and it wasn’t purely the accolades; it was about instilling change.

I also admire LeBron James. We have a very similar story: the Cavs with LeBron and MetroHealth with Akram; many, many of the same people working a little bit differently together, focused on a greater good than on individuals. I’ve learned a lot from him.

What is the best business advice you ever received?

This was from David Garvin, Ph.D., at the Harvard Business School: fail effectively. It has three components to it. Fail small, fail fast and fail forward. Don’t make huge mistakes, but you’re bound to make mistakes. Make small ones. Fail fast; don’t wait too long to make a decision because it’s bound to be wrong anyway, so you might as well just get it over with. Fail forward means to learn from your mistake and just move on. That’s when you can transform failure into learning.

What is your definition of business success?

Creating an organization that provides value and is sustainable without you, that fills its purpose, has good operations, good methodologies, good structures, is hopefully adaptable and it doesn’t need you for it.