Clinical Trials: Lessons Learned Starting a Clinic
by the Rev. Dr. Michael Gemignani
On March 3, 1999, after more than a year of planning, writing grants, negotiating, and remodeling, what is now the Brazosport Medical Center opened its doors. This venture to provide health care in a medically underserved and demographically challenged section of Brazoria County, Texas, was made possible by generous grants from Episcopal Health Charities that enabled us to buy and renovate the building in which the clinic is located. The opening of the clinic marked the beginning of a long and sometimes painful process in which I learned many important lessons about starting such a venture.
The first lesson I learned was that the name we had first chosen, the Southern Brazoria County Clinic, was a disaster. We soon found out that folks thought we were funded by the County and were offering free medical care to anyone who walked through the door, neither of which was true. We quickly changed the name to the Brazosport Medical Center.
But this first lesson, that a poorly chosen name can have unanticipated and unwelcome consequences, was only the first of many lessons learned over the course of two chaotic years before the Center finally achieved stability and could honestly present itself as meeting its intended purpose. I share below other lessons gleaned from those two years. If you already had to learn them yourself in connection with a civic project, clinical or otherwise, you may gain comfort that someone else had to learn them too. If you are thinking of starting a major civic project, then you may be able to learn from my mistakes. With that in mind, I offer you the lessons I gained from my clinical trials.
Lesson 1. You won't know what you are getting into until you are into it.
This lesson might be rephrased: Things never go the way you expect them to. You might attribute this in my case to my lack of experience in starting a clinic, and, to some extent, you would be right. But we brought a consultant in when things were not going so well to help us figure out what we were doing wrong. This wonderful woman had, over many years, started and managed a number of clinics. She told us that for the time we had been in business, we were doing quite well. She also said that, no matter how many clinics you start, the first year is sheer hell. Maybe it would have made me feel better if I had known that ahead of time, but maybe it would have also discouraged from starting the project in the first place.
How do things do wrong? In any number of ways. Your ways will probably not be my ways. Each project depends heavily on the individuals associated with it and the environment within which it operates. No matter how carefully you plan, you will not know what you are getting into until you into it.
2. If are not good at problem solving on the fly, you had best work with someone who is.
I have significant administrative experience and am a member of the Texas Bar. I believe that I can size up most situations quickly and come a decision in short order that I can logically support. However, I am not trained in medicine or in architecture. Issues arose in both of these areas that impacted the clinic. I was blessed by having a retired architect who donated tens of thousands of dollars worth of his time to help bring the plans for the renovation of our building into a price range we could afford and who made sure that the work was done right. Persons who knew the ins and outs of regulations governing medical clinics also came to our aid.
Of course, decisions not only had to be made, but they had to be made in real time. Contractors would not stand idly by while I researched the rules for handicapped access or decided where the lavatories should go. I had people helping who could solve those problems for me because they were informed in areas in which I was ignorant. Since you, no matter who you are, cannot know all you need to know to carry out your project successfully, you will need to make sure you have folks around you who will fill in the knowledge gaps and have the administrative or other skills in which you are weak. A good leader is not necessarily one who has all the knowledge needed for a particular task, but one who can gather a team that collectively shares that knowledge and who can enable that team to work toward a common goal.
3. You will learn how to pray if you did not already know.
More than once I went to bed certain that the clinic would either never open, or, once opened, it would fail. Every time that I prayed that if God wanted the clinic in Freeport, God find a way to solve the seemingly insoluble problem it faced, a door opened in the wall we had hit so that we could go forward again. There will be times when you know that events are beyond your control. Don’t dismiss the power of prayer. My church continues to pray for the Medical Center every Sunday.
4. Those people you thought would be the most help may let you down, but help may come from unexpected sources. Keep your eyes open.
Episcopal Health Charities, the agency that gave us our initial funding, was immensely helpful with both guidance and providing us with useful contacts. But some of the people and agencies that seemed most interested in the project in the planning stages soon dropped out once they were asked for substantive support. On the other hand, help often came in unexpected ways, e.g., the retired architect who saved us so much money and oversaw the renovations. Our first three primary care providers did not work out, each for a different reason, but a nurse practitioner who was impressed with what was happening at the Center agreed to take over our primary care and has done a wonderful job. Always be looking for people who can help you, and don’t be surprised if those who were initially enthusiastic drop out when they are asked to provide more than ideas. Look for folks who appreciate the vision you present – you do have a vision, don’t you – and who will stick with you for the long haul.
5. Have a clear vision for what you want to do going in, but be flexible enough to modify it as reality dictates. People will often contribute time and money toward achieving a goal with which they can identify. Fuzzy goals usually produce less than satisfactory outcomes.
Indeed, having a clear vision for your project is essential to success. Episcopal Health Charities became interested in our proposal because we could document that Freeport was seriously medically underserved and the population was economically disadvantaged. We could articulate concisely what we wanted to do: Provide quality, affordable health care for a medically underserved area. Originally, the vision encompassed only primary care on a part-time basis for indigents. Because of opportunities that opened up later, we expanded our vision to include additional services. We now have seven different providers housed in the Center.
Originally, too, we thought we would provide services at the Center at little or no cost to the patients. We quickly learned that this was not feasible and made adjustments in the planning toward establishing a program that would be financially viable.
If you cannot clearly and concisely articulate why your project is needed, you should not expect others to share the urgency about it you yourself feel. If the need is not well-documented, then potential funding sources are not likely to be impressed. But be sure that your vision is practicable and not pie-in-the-sky. Few funding sources will underwrite building a perpetual motion machine.
6. There is no such thing as free medical care.
It never ceases to amaze me how many people think they are entitled to free medical care. There is nothing wrong with wanting medical care. I believe every citizen should be guaranteed a certain level of medical care. But medical care is never free. Someone is paying for it. That someone may be a physician who is donating time, or a granting agency, or the government or an insurer, but someone is paying for every bit of medical care provided to anyone anywhere. Anyone who starts a clinic with the idea that it will give free care to all comers, or even to all indigent comers, had better be a world-class fund raiser or have substantial personal wealth she will invest in the venture.
There are a variety of methods for paying for the medical care. Some clinics charge a flat rate to all patients and do not bill insurers. Some bill insurers like medicaid and charge a nominal fee for those who have no insurance at all. Some depend on the donated services of health care professionals. But no one can say that the services they provide are gratuitous. You cannot stay in business very long by giving your product away.
7. It takes hard work and a number of years to get a working board with members who are willing to put the time needed to contribute significantly to the venture. Building a board will be one of your most difficult tasks.
I learned that one of the most difficult jobs I had associated with the clinic was putting together a working board. Many of the people you would like to have on your board are already too busy. They may agree to lend their names, but they will often not be able to spend much time on committees, raising funds, promoting the clinic, recruiting volunteers, or doing other tasks that board membership might require.
The worst sort of board member is someone who likes to boast about being on a board and has no genuine interest in the work entailed in such membership. Other board members who are not helpful are those who think they need to manage the day-to-day operations of the clinic or gain special treatment for their family or friends.
Board members should share the vision for the clinic and understand that the role of the board is to develop policy, hire and supervise the executive director, and support the work of the enterprise. Board development, teaching the board to be a board, and members to carry out their roles responsibly, is vital if the board is to be healthy and functional.
Persons may be invited to join the board for different reasons. Some may have special expertise, e.g., such as legal or financial. Some, such as executives in local industries, may have access to potential sources of volunteers or funding. Some may be associated with a newspaper or hospital and can provide contacts and information that will assist the work of the board and the clinic. But putting together a balanced board whose members share your vision and who are willing to spend time and even treasure to make sure the vision is realized is one of the most important tasks you will face. It took me more than two years to get a board that functioned for the most part as it should, and we are still working on it.
8. The first year or two will be sheer hell. If it isn’t, you probably don’t have a clear picture of what is happening.
Remember what my consultant who had started many clinics told me. The first year is always sheer hell, and it doesn’t matter how much previous experience you’ve had starting clinics. Plan on two years of sheer hell if you have had little or no experience starting a clinic.
9. Ask for help. You may be able to get invaluable advice cheaply or even for free. An outside consultant might be a good reality check. The funding agency can probably put you in touch with a capable consultant. Episcopal Health Charities did this for me.
There is the old joke about the Israelites having to wander forty years in the wilderness because Moses would not stop and ask for directions. If you find yourself in over your head on some issue, or you feel the need for a second opinion, ask for help from someone who might give you informed guidance. Who might you ask? First, the granting agency who funded you, if you are already funded, might have some excellent suggestions, as they did for us. Second, you might approach persons with relevant expertise and ask them to donate an opinion. They might be willing to look at your problem and give you suggestions. Once again, here it is vital for you to have a clear vision of what you are trying to accomplish to aid the consultant in evaluating whether you are on the right track, or even asking the right questions.
10. Even though you are only working for the benefit of society, there will be those who think you are in competition with them, or who believe you are taking business away from them. Be prepared to show clearly what you are trying to achieve and why it does not duplicate existing services or compete with for-profit enterprises. Usually you are serving clients that no one else wants. Here again a clear vision of your enterprise is a significant aid in explaining it to others.
When we were well along on constructing our grant proposal, we found that a number of doctors in a neighboring city were not happy with our idea because they thought it might take paying patients away from them. Several meetings were needed with the medical community and with representatives of our area hospital to iron things out. We were not in competition with the physicians. We were directing our efforts at patients they generally did not want and, often, would not see. We were able to make the case that none of them was practicing where the Center would be located and none of them wanted to practice there. We were able to argue convincingly that we were not duplicating the work of the physicians or the hospital. In fact, we would be helping the hospital by treating patients who might otherwise come to the emergency room.
In this case, the opposition was withdrawn. However, in some cases you may discover you are duplicating the work of another agency in the same area. In such an instance, it might be better to collaborate than compete, or find some unmet need to fill.
11. Keep good records. You will need them if you want to become a member of United Way, get 501(c)(3) status, write reports to your granting agency,, make your case to the community, and write more grant proposals. Most funding agencies do not deal well with B.S.
I found this out when I had to come up with records for our first IRS Form 990 report as a 501(c)(3) corporation and for our first audit. We were able to produce all the records, but I had to scratch to find some of them because I did not at the beginning recognize how important these records were or how they had to be organized. Our application to become a member of United Way was lengthy and detailed. In applying for grants, I have learned that most granting agencies require a recent audit, a copy of your Form 990, budgets and usually other stuff as well. Government agencies are particularly burdensome in their paperwork. Once you get a grant, more often than not you then have to make a detailed report on how you used the grant. Good records are essential and will save you lots of time in compiling the information granting agencies require, often i differing formats. Maybe you can do without grants or audits or the IRS, but I doubt you will survive.
12. Be sure you have a staff administrator to run the operation on a day to day basis unless you have nothing else to do with your life. Do not forget to write administrative help into your grant proposal.
One serious mistake I made in my initial application for the funding to establish the Center was not including funds for an Executive Director. The mistake was innocent in the sense that a primary care provider had assured me he would act as the administrator for the Center. He proved inadequate to the task – physicians are often terrible administrators and businesspersons – and he did not report to the Board so the Board could not fire him. We had no money to hire our own administrator. I had to go back to Episcopal Health Charities, hat in hand, and ask for funds to get us started with a professional director who reported to the Board. This was after I spent about a year as de facto director, a task for which I was not trained and which consumed more time than my duties with my church. Don’t be foolish enough to assume you are going to be able to run things at your clinic unless that is your day job, in which case you need to solve the problem of who is going to supervise you.
13. Be prepared for the long haul. It took almost three years before the Brazosport Medical Center was accomplishing its goal to provide low-cost, affordable medical care for an under-served area. Many times during those first two years I was afraid we would never make it. Do not give up.
Keep plugging. As I noted earlier, there were several times I thought I have to throw in the towel, but, by the grace of God, we were able to solve seemingly insoluble problems. Without the constant and continuing effort, the clinic would have failed. It isn’t over ‘til it’s over.
14. There must be someone, other than a member of the paid staff, who feels a intense personal commitment to the clinic and who is in a position to act on that commitment. If no one thinks of the clinic as his or her “baby,” then there is a good chance of failure. The reason is that problems will arise that threaten the viability of the clinic, especially in its early years. If no one is in a position to work constructively toward solving those problems and has the drive to do so, they will not be solved.
This is simply an extension of the previous observation. If I personally had not been so committed to the Center, it would have failed. Maybe I truly felt God wanted that clinic in Freeport, or maybe I just did not want to have egg all over my face, but I was determined to see the project through, often at considerable cost in energy and time. I “owned” that project. I was to the Center what a parent is to a child. If there is no one who “owns” the project, if there is no one who feels that his or her child cannot be allowed to die, then this lack may prove fatal to the project. If you want to start a clinic, you must care deeply about that goal and be willing to devote a good deal of your life, at least for a time, to achieving it. Once it is established and stable, and you have trained leadership to succeed you, you can walk away knowing your child can survive without you. If you walk away before that time and there is no one else who holds that project in his heart, the orphan may not survive.
So, if you want to start a clinic, may God bless you. If you read this article before starting your clinic, I hope you will find some salutary guidance. If you read it after starting your clinic, I am sure you will recognize much that accords with your own experience.
