Since the flood of child migrants from Central America burst upon the southern United States in the summer of 2014—a vast rise in arrivals dubbed “the Surge”—Kids in Need of Defense (KIND) had been facing overwhelming demand for its legal services. Wendy Young, KIND’s president, explained that the organization’s primary mission was to ensure that no child appears alone in immigration court, but KIND also wanted to provide leadership, research, and advocacy to protect these “children on the move” from laws and practices that threatened their fundamental human rights. Ms. Young was facing a critical juncture in the organizational life of KIND: where and how should it focus its resources for greatest effectiveness in protecting child migrants? What limits must the organization set on its activities when facing an almost unlimited need for legal, social, health, and educational support of these vulnerable children?

Dr. Laurie Gianturco (“Dr. G.”), Chief of Radiology at Baystate Health and President of the private imaging practice Radiology & Imaging, Inc. (“R&I”), and her partner for this project, Suzanne Hendery, VP of Marketing & Communications at Baystate Health, considered their new assignment. With Baystate leadership’s full executive sponsorship and support, but no additional budget, they were tasked with consolidating two competing practices—one operated by R&I, the other by Baystate Medical Center—to form a new breast services center under the Baystate umbrella. The consolidation would simplify redundant Baystate-affiliated breast services offerings, making the system less confusing for patients and providers while giving Baystate the opportunity to offer more patient-centered services as well as reducing its operating costs and boosting revenues. They knew it would be a complicated project, involving two competing physician practice cultures, three clinical specialty orientations, the potential disruption of existing referral networks, and the merger of imaging services for healthy women along with treatment for women with breast cancer. Despite these challenges, they banded together to define a patient-driven culture, create an integrated program, and build a strong brand anchored by the new facility. Their goal was to gain a competitive advantage by developing a relationship-based approach that would exceed customer (patients and referring physicians) expectations for service. “The financial argument was the easy part,” Dr. G reflected. “How to actually design a model of care is where we came to an impasse.”