The terms “Upstream” and “Downstream” are important to incorporate into the enterprise vocabulary in order to have meaningful discussions about the entirety of the Value Creation Process. The reason is that upstream processes can significantly impact the downstream processes. But if not considered as parts of the Value Creation Process, they can be siloed in communications, create various bottlenecks along the Organizational Value Stream, and decrease overall system throughput in capacity and velocity.


Upstream – Is the collective of processes that happen prior to acquisition (deal closing date). They are usually similar to a classic sales funnel and have conversion rates associated with various stages. As the hospital progresses through the funnel, it can churn because it does not pass the Strategic Filter of the organization.

Downstream – Is the collective of processes that happens after the Close Date and starts with the integration — proceeding to Stabilization and Change Management. If the Business Development team is not adherent with the Strategic Filter, the practices that get acquired do not fit the Value Creation Plan. Therefore, they are not a candidate for Value Creation with the processes that are established at the organizational level, or have cultural misalignment leading to various triggers of burnout as well as inability to implement change post acquisition.

Another reason to pay attention to the connection between these two parts as one Value Stream is Capacity Management. The capacity could be managed by understanding the bottlenecks in the system and throttle the throughput according to the most narrow part of the Value Stream. One can become concerned that the deals are not able to wait, because someone else will acquire them. This risk is mitigated by creating a buffer state — “stabilization” — in which the practices are “parked” after acquisition with minimally-invasive centralized processes being applied to them.


If the system is not designed for a continuous monitoring of the upstream and downstream connection, this may slow down the acquisitions or fail during integration — all which will lead to inability to implement change downstream. This ultimately leads to failure of creating Value for the enterprise as a whole.


  • Prospect Hospitals Pipeline
  • M&A
  • Culture/People Integration
  • HR Process/Onboarding
  • Core Processes Implementation
  • Strategic Filter
  • Prioritization (WSJF)
  • Pre- and Post-Acquisition Assessments
  • Training
  • Implementation of VCP Processes
  • Capacity Reservation Process
  • Change Management
  • Data-Driven Change Management
  • Data-Driven VCP Initiative Process


The most common reason for burnout during and post acquisition is when the new process is rolled out at the hospital level l before the previous process was completed with all Definition of Done (DoD) criteria satisfied. A further change readiness assessment should be conducted to determine if the practice is ready for new change. These triggers are the most common result of inappropriate management of the Upstream & Downstream: Lack of control, value conflict, work overload, unfairness, and breakdown of the community.


De-novo and franchise models have the advantage of the system design upfront and have an opportunity to perfect this Value Stream at the inception of the organization. Continuous improvement and analysis of the bottlenecks should be conducted regularly and reviewed during Operations/Risk meetings.