In a previous article, I shared perspectives on affiliations from an academic medical center. This article looks at affiliations from the vantage point of community hospitals and physicians. For purposes of these articles, I've defined an affiliation as "any relationship between otherwise independent health care providers designed to create shared advantage and value."

Augusta Health

In 2011, Fishersville, Va.-based Augusta Health entered into an affiliation agreement with the Durham, N.C.-based Duke Cancer Network, the goal of which is to provide seamless integration of cancer care and research. Among the benefits the Duke affiliation brings to Augusta is access to 300 Duke University researchers and physicians from 27 departments and seven schools supported by more than $300 million in cancer research funding.

The Duke affiliation proved transformative for Augusta. It allowed the organization to significantly leverage clinical strengths already represented in the capabilities of its medical staff. According to Augusta Health CEO Mary Mannix, "Physicians, particularly those operating in the community, tend to be pragmatists. They want to see tangible value that translates into improved patient care and practice productivity. Absent that, things don't get traction. Our Duke affiliation has traction."

When it came to an affiliation with an academic medical center, Mannix, as well as Augusta's board and physician leadership, were seeking clinical expertise that complemented and expanded what they already had. 

Productive Relationship

For Augusta, access to Duke's clinical and research protocols is vital, as is a desire for increased access to clinical trials. Much of the clinical consultation is delivered through Duke's telehealth system. According to Mannix, "Duke is 190 miles away. They didn't have an expectation that we would be sending patients to Durham. They understood what we wanted most was complementary intellectual firepower and experience that could be delivered locally."

“To be honest,” she says, “one of the most important attributes they brought to the affiliation was an attitude of respect and helpfulness. Duke wanted to see us expand our clinical capabilities. They've worked shoulder to shoulder with us to achieve alignment."

For Duke, affiliations beyond its regional service area provide a broader and more diverse population base for its research mission, including its commitment to innovate in the delivery of care at a distance.

Characteristic of the support Augusta has obtained from the affiliation are services that strengthen performance improvement, education, regulatory compliance, and case review. Through attitude, commitment, and infrastructure, Mannix observes, "Duke is in the room with us, with our patients and our physicians, and with our community." According to Mannix, "'Consultation' is at the heart of what we get from Duke. That includes physician to physician clinical consultation. It also includes programmatic and administrative consultation."

One of the things that has helped make the relationship productive is the dyad structure in place at Duke, which teams a seasoned administrator with a faculty physician. "Because they are so focused on their subspecialty and research, faculty at academic medical centers and subspecialists at tertiary referral centers don't always have a very deep appreciation for the administrative and business challenges associated with delivering care, particularly in a private-practice community setting. An administrator can help bring that perspective,” Mannix says. 

Augusta pays a fee for the services and expertise it receives through its Duke affiliation. There are contractual elements related to the affiliation agreement, including an exclusivity agreement that protects the relationship across Augusta's regional service area. Absent such exclusivity, the affiliation's differentiation could be diluted.

Mutual Expectations

Essential to making the Augusta Duke affiliation work has been an alignment of values. Related to co branding, leaders at Duke have emphasized that, "for it to have Duke on it, it has to have Duke in it." As the relationship was being formed, early discussions centered not on clinical questions but on shared values. Duke also emphasized commitment to the affiliation from the top of the Augusta organization, including the board, the executive team, and physician leadership.

Augusta's executives and its board pay close attention to performance metrics, including those they use to assess their Duke affiliation. For example, the cancer service line is assessed based on frequency of consultations as well as service utilization and preference.

Critically, Augusta's affiliation with Duke hasn't precluded the pursuit of other relationships, such as collaboration with Carilion Clinic in Roanoke, Va., related to primary care. Carilion employs several of Augusta's key primary care providers. These physicians are very strong citizens in Augusta's medical community. 

Tidelands Health

For Tidelands Health CEO Bruce Bailey, a high value affiliation brings capabilities that a community hospital would find difficult or impossible to deliver on its own. According to Bailey, "There are thresholds of volume below which a community hospital can't provide subspecialty capabilities. For this, it needs a partner that's able to aggregate enough volume across multiple communities. Pediatric subspecialty services are a prime example." 

For this and other services requiring a large population base, Tidelands, a two hospital system based in Georgetown, S.C., relies on a well-established affiliation with the Medical University of South Carolina, located 85 miles down the coast. The relationship has grown naturally over many decades and is deeply rooted in collegial interaction between community physicians and their faculty colleagues at MUSC.

Physicians on staff at Tidelands have suggested that attitude and culture have been key ingredients in building trust in the affiliation. Many of them trained at MUSC and grew up in the Low Country. As one physician commented, "There's not much of a town/gown dynamic. MUSC faculty demonstrate respect for the physicians providing frontline care in the community."

Currently, Tidelands' executive team is working on redesigning its service-line management structure to make it easier to relate to service-line leaders at MUSC. The new structure will enable managers to more effectively collaborate on design and delivery of care across Tidelands' population base. "You've got to focus," Bailey suggests, and "you've got to ask, 'What are the services and programs that will benefit most from focused communication and collaboration?'"

According to Bailey, it's often hard to relate with complicated organizations like academic medical centers and subspecialty regional referral centers. "It's not that they don't try hard to be accessible and responsive,” he says. “It's just that they are so big." Sensitive to the challenges of size, MUSC launched an organization-wide initiative to enhance access not only for referring hospitals and physicians but for patients as well.

Shared Commitment

Among the efforts that came out of the affiliation was the development of a Family Medicine residency program at Tidelands. It has been a "win win" for Tidelands and MUSC. Tidelands needed primary care providers, and MUSC needed training and practice sites. 

Not all the gaps are clinical. Tidelands' needs for data and management expertise are growing as population health and value based care become more important. MUSC is developing deep capabilities in those areas. Affiliation with Tidelands expands the population base against which to amortize that investment. Affiliation also provides an opportunity for Tidelands to "bolt onto" MUSC's clinically integrated network and accountable care organization initiatives, again helping to amortize the cost of the infrastructure necessary to support those initiatives.

At a high level, Bailey and the leadership of MUSC recognize that meeting patient needs in the coastal region that extends from the North Carolina border to the Georgia state line will be a key to long term success. Achieving that will require strategies, services, and access that are coordinated and cohesive across the regional population served.

Located in Charleston, MUSC sits midway in South Carolina's coastal market. Tidelands anchors the northeast portion of that regional market. MUSC has also developed affiliations with anchor community hospitals to its north and to its south. 

Bailey emphasizes that "Charleston has become one of America's favorite cities.” “Its growth is booming,” he notes. “Eventually, that growth will spill over into bordering communities, including Georgetown. It behooves us to work together in thinking through how best to deliver high value across a swelling population. One of the things we've done through our affiliation with MUSC is sponsor joint strategic planning focused to our market." 

Tidelands' executives, board members, and physicians all participated in developing that joint strategic plan along with counterparts from MUSC. MUSC also conducted similar joint strategic planning with other affiliated community hospitals. It was an invaluable investment in creating a shared view of opportunities and challenges as well as the dynamics unique to each organization.


A robust affiliation is not a melding of visions or the consolidation of two sets of strategies and goals. It has to have its own vision as well as its own strategies, and these need to be well anchored to the needs of the patients and communities served. Such mutual commitments need to be adhered to with discipline or the affiliation is likely to deteriorate into short term reactiveness.

One thing is clear to me, however: the need to be connected is growing. Defining, developing, managing, and leading system affiliations has become an essential competency. As Russell Ackoff once observed, the focus of leadership in a "nonsystem" is on "actions." In a "system," the focus is on "interactions."

Author’s note: Christopher Beckham, vice president of The Beckham Company, contributed research for this article.

Dan Beckham is president of The Beckham Company, a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to AHA Today. 

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