Los Angeles County Health Services Director Mark Finucane doesn't fit the stereotype of the typical bureaucrat: He's accessible, likable, competent and without a doubt in complete control.
Finucane leads the public health system for the nation's most populous county, serving 8.5 million people through six hospitals, 39 clinics and 22,000 employees strewn over 6,000 square miles. Aside from delivering inpatient and outpatient healthcare, his agency performs ancillary tasks such as overseeing the countywide trauma system; training medical residents and running a nursing school; investigating problems at privately owned hospitals in the county on behalf of the state health services department; and inspecting restaurants, grocery stores and other providers of prepared foodstuff.
Finucane's primary mission for the past 31/2 years has been to slowly transform the department's caregiving from an inpatient- to an outpatient-based system, and to change the department's culture to make sure needed change takes place.
Finucane's vast job responsibilities require him to spread himself pretty thin. He juggles a relatively small $2.4 billion annual budget against the endless task of modernizing public healthcare delivery while still pleasing his politically motivated bosses, the five-member Los Angeles County Board of Supervisors. It's a job that's stressful and at times even treacherous.
"It's a punishing job-not only just demanding of your skills, but in a physical and emotional way I didn't expect," says Finucane, who has held the post since January 1996. "It's like getting on the freeway at 85 miles per hour. The pace is unrelenting; from the moment you walk in the door until you leave, there's a flood of demands on your time."
Orchestrated criticism. Moreover, Finucane endures a constant barrage of criticism. It comes primarily from the board of supervisors, although observers say most of it is not out of ill will but carefully orchestrated for political impact. Finucane says he's usually consulted before any hard-hitting rhetoric is issued.
"I'm amazed at his capacity to take abuse. I've been appalled at the way they treat him, and I don't think it's necessary," says Brian Johnston, M.D., chairman-elect of the Los Angeles County Medical Association, a past president of the association and chairman of the emergency department at 354-bed White Memorial Medical Center, near downtown Los Angeles. Johnston has worked closely with Finucane over the years on numerous issues.
Finucane's toughest critics on the board, Supervisors Gloria Molina and Zev Yaroslavsky, did not respond to repeated requests for interviews. However, Molina's spokesman Miguel Santana says his boss approves of much of what Finucane is doing.
Finucane's department provides more-genuine sniping, according to observers.
Jim Lott, executive vice president at the Healthcare Association of Southern California, says Finucane makes it clear that the county must do business differently, partly by working more closely with private providers. "The attitude of many of the county people is that they can do things better than the private sector and that change is not necessary," says Lott, who is co-chairman with Finucane of a county healthcare advisory committee. "He has few people in the department he can truly trust-they can probably be counted on the fingers of one hand."
Finucane doesn't deny he navigates hazardous waters: "The size of the system leads to visibility, then second-guessing. It's a regular part of the landscape."
But despite the toll his job takes, Finucane says, he loves his work. "It has its difficulties, but I get to move a lot of heavy furniture from a policy standpoint, and that's what I like to do best," he says. "I've got the best job in the country."
As for the daily buffeting he endures, Finucane copes by what appears to be tight compartmentalization. His downtown Los Angeles offices, while spare, have an air of clean organization that is rare in Los Angeles County government workspaces. Finucane's intense, almost obsessive devotion to running and healthy living is countered by an attentive, nearly courtly manner. Yet during a recent interview, his delicately arranged segue to an off-the-record comment was followed by surprising bluntness. A day later, he made a follow-up phone call to inject an angle he thought had been overlooked.
"I wouldn't say I'm a controlling individual," Finucane says when pressed. But he adds: "I'm quite capable of being in control. It really depends on the situation. I prefer to see myself as influential."
Finucane's striving for influence should not be a surprise. At 51, he is among many who experienced the 1960s counterculture but were later pressured by the high expectations placed on early baby boomers. Indeed, Finucane "bummed around" for years-enlisting in the Army for a four-year stint and achieving the rank of specialist first class, and managing a rock band-before he earned his bachelor's degree in English from Wichita (Kan.) State University at the age of 27. However, he has used a B.A. to lead a department filled with many staffers holding advanced degrees. He also is a devout Bob Dylan fan and uses Sun Tzu's Art of War as a management text.
Happenstance intervenes. Finucane's entry into a field dominated by careful career planners was in many ways as happenstance as his resume. After college, he worked as an administrator in the Wichita public school system and was seriously considering law school when system Superintendent Mervyn Silverman was appointed to head the health department in San Francisco. Silverman hired Finucane as his executive assistant.
After a period with Silverman, Finucane worked in several government posts in San Francisco before heading Contra Costa County's health services department in 1984. He served there 12 years before winning the Los Angeles County post.
Although Finucane jokes that his career path "rescued me from being a lawyer," he says his humanities degree and diverse experiences prepared him to do a proper job.
"I got a good core education that gave me critical-thinking skills," Finucane says. "There's nothing wrong with an advanced degree, but my experience regarding how well a person with one fares in the world is, it depends on the core of the individual."
Finucane's management core is based on communication. He continuously circulates his changing "A List" of projects among staff and has fostered communication on a level his predecessors never dreamed of, observers say.
At the same time, he's a tough operator, who told his staff that those unwilling to embrace change should leave. Although most of those people left voluntarily, he quietly moved out a number of senior managers who wouldn't cooperate with his planning. "I was hired to change the department, not be changed by it," he says.
Dublin revisited. Those who are loyal to him and willing to make changes-about 25 managers in all, he says-are included in his 90-minute "Rathgar Group" meetings every other Monday. The name comes from Rathgar Road, the street where he lived when he studied at Trinity College in Dublin during his undergraduate years.
"I came to the conclusion that I needed to meet on a regular basis with people I call change leaders either by appointment or attitude," says Finucane. "It may just be the distance from Dublin, but I wanted a name that signified something very different."
Lott says that's typical of Finucane. "He has brought a skill and talent for communication into a very difficult job and has made it quite positive," he says. "He won't take anything to the supervisors without consulting all the stakeholders: the community clinics, unions, hospitals, welfare rights organizations and physician organizations. He doesn't satisfy them all the time, but there isn't a person in the group that can't get an answer from him. That kind of honesty buys a heck of a lot of credibility."
Everyone agrees that Finucane acts when change is needed. Johnston praised him lavishly for allowing county-employed physicians more autonomy in making patient-care decisions, for example. And rather than lie low after a local news station delivered a scathing report on restaurant cleanliness problems, Finucane stepped up health inspections and pegged the results to letter grades. Restaurants must post their grades prominently in their front windows.
The practice proved embarrassing to Los Angeles Mayor Richard Riordan, whose legendary Pantry restaurant fared so poorly on an initial inspection that it was nearly closed during the Thanksgiving rush in 1997. Yet the letter grading of restaurants has quickly spread to many adjoining counties.
Finucane's main goal, however, has been to inch the county's antiquated inpatient-based care toward an outpatient model. He has also overseen often contentious planning for the replacement of the system's largest hospital, 1,330-bed County-USC Medical Center, just east of downtown Los Angeles. Finucane took the risk of supporting a smaller, 600-bed hospital when some of the supervisors wanted a 750-bed facility. A final decision has yet to be reached, but the county's board of supervisors is leaning toward building a smaller hospital.
Most observers agree that Finucane's commitment to public health has been the cornerstone of his administration.
"There haven't been any empty promises from Mark," says Mandy Johnson, executive director at the Community Clinic Association of Los Angeles County. "He's laid out a commitment to expand ambulatory care and partnerships with the private sector."
Johnson notes that when Finucane took the job, the department of health services had little contact with the private sector. Just three years later, the county has entered 149 public-private partnerships.
Hazards of ambition. Yet Finucane's track record has fallen short of his ambitious agenda in some areas. When he was appointed three years ago, he was charged with transforming a system that relied mostly on inpatient-based care, which had driven it to the brink of insolvency. The system was bailed out only by a five-year grant of cash from the federal government-known as a waiver-which began in 1996 and may eventually top $925 million. But there was a catch: The system had to cut costs.
Despite scores of public-private partnerships, the county is expected to realize only $82 million in cost savings over the life of the waiver. That is far short of the $294 million originally projected, a figure the federal government factored into the amount it decided to grant the county.
Outpatient visits are also falling short of projected goals. Finucane admits being overambitious, conceding his department was overwhelmed by the stunning complexity of its plans. He is pressing for a five-year extension of the waiver and expects it to be secured.
Although some politicians criticized Finucane for the shortfalls, few providers blame him directly. Johnson and Lott cite many mitigating factors affecting outpatient-care expansions, including the complexity of caring for an ill-patient base, hiring freezes at county clinics and the quickly changing agenda of the board of supervisors.
Still, Finucane's supporters don't hesitate to criticize him when they disagree. For example, Lott and Johnston have slammed Finucane's handling of outsourcing of inpatient care to the private sector. Lott said his group's members were particularly upset that a lack of funds led to the cancellation of two demonstration projects that would have allowed private hospitals to treat county patients.
"His reasoning was simple and straightforward, and I don't have to like that response. But I accept it and the logic behind it," Lott says.
Ironically, the often scattershot criticisms of Finucane may have contributed to his longevity, Johnston says.
"Those who are unhappy with him tend to be that way for various reasons," Johnston says. "If there was ever a consensus, he'd be in a lot of trouble."
Perhaps Finucane senses this. He says he has settled into his job. He works about 50 hours a week, down from the 60- and 80-hour workweeks of the first year of his administration. He attributes that partly to a higher comfort level but also to a chain of sad personal events.
In December 1996, while rushing to get to the California Public Hospitals Association annual meeting, he slipped on an oil spot in a parking lot and fractured six ribs and broke his collarbone. Finucane subsequently developed a deep vein thrombosis and was treated with Coumadin for six months. On March 8, 1997, his older brother Jim died of a heart attack at 53. His mother, Rita, passed away almost exactly a year later.
"Those events will slow you down far faster than any recommendations from a management consultant," Finucane says.
Meanwhile, Finucane's long-postponed task of buying a house in the Los Angeles area recently ended with a purchase in South Pasadena. Finucane had hopped a flight every Friday evening to Northern California to be with his family, saying he delayed the move out of consideration for the schooling of his two daughters. But others have read far more into the move.
"Buying a house means he's sure he's not going anywhere for a while," Lott says.