In early 2024, two Missouri health systems—BJC Health System in St. Louis and Saint Luke’s Health System of Kansas City—combined to become a single, integrated healthcare organization. The union brought together two of the region’s most respected health systems, uniting their academic expertise and clinical capabilities to serve patients across Missouri, Illinois, Kansas, and the broader Midwest.
The integration took place during a time when health systems nationwide are navigating an increasingly complex landscape of rising costs, workforce shortages, and growing demands for improved access to affordable, high-quality care. By joining forces, BJC and Saint Luke’s aim to set a new standard for integrated care delivery, combining their collective strengths to expand access, improve patient outcomes, and drive innovation across a larger geographic footprint. The new organization’s approach to combining academic medicine with community-based care serves as a blueprint for other health systems seeking to balance excellence with expanded reach.
In this episode of the McKinsey on Healthcare podcast, Senior Partner Drew Ungerman speaks with Rich Liekweg, CEO of BJC Health System, and Nick Barto, president of BJC Health System, about the unvarnished realities of combining two large organizations in today’s challenging macroeconomic environment and the importance of culture and leadership in making that combination a success. Since recording this episode, Liekweg has announced his retirement following a 40-year career in healthcare, including the past 16 years at BJC, effective October 1, 2025. Barto will succeed him as CEO of BJC Health System.
What follows is a lightly edited transcript of their conversation.
Drew Ungerman: We’re here to talk about the exciting combination that you helped shape and lead. I want to start at the beginning: What inspired the idea to integrate BJC and Saint Luke’s?
Rich Liekweg: BJC and Saint Luke’s had a ten- to 12-year relationship before we formally joined together at the start of 2024. We had formed an organization called the BJC Collaborative, and because of that relationship—and because we knew each other so well—Dr. Mindy Estes, the CEO of Saint Luke’s, and I had conversations about what we both felt we needed to do given some of the headwinds that were affecting the industry. That discussion led us to the idea of joining the two organizations. It really was evolutionary, not revolutionary, given our long-standing relationship.
Nick Barto: To build on Rich’s point, both leadership teams and both boards were forward-thinking and saw change coming in the industry. And I think both boards and both management teams wanted to stay ahead of the changes that were coming at us. Obviously, this has proved to be fortuitous, as we’ve now been together for a year and continue to operate in our current environment.
Drew Ungerman: You both, and BJC Health System as a whole, are in the business of taking care of people and your communities. How has joining the two companies helped create value for patients and the communities you serve?
Rich Liekweg: Both of our institutions have been in our communities for generations, and we’re both very proud of the exceptional care that we provide in the communities that we’re privileged to serve. In coming together, one of the initial goals was to make sure that we’re going to be here for future generations and, at a minimum, maintain the access to care that already existed.
We then wanted to take it one step further and expand access for the communities we serve and the communities we wanted to serve in the future. We believed that the size and scale we would achieve by joining together would help us better innovate and better invest capital to ultimately serve our most important customers: our patients and the communities within which we operate.
Nick Barto: That scale also allows you to attract talent—both clinical talent and talent in shared service areas, like finance, managed care, and supply chain. People want to play for a winning team. That scale, along with the commitment to being around for the next hundred years, creates a great platform for attracting talent. In addition, the long-term stability of the organization is important for patients. If you’re investing your time and effort in creating relationships with a healthcare organization, knowing it’s going to be there for you and your family for years to come is important.
Drew Ungerman: The industry doesn’t have the best track record with these combinations. What were you most concerned about, going into an integration of this magnitude?
Rich Liekweg: We knew we had to convince our constituents that this was the right time to take this very bold move. At the time, each of us was operating a very successful healthcare system, so there was not a real burning platform. In some ways, it may have been easier if one of us was not performing as well as we were. As it was, we had to convey the enhanced value we were going to bring to the community and our stakeholders. We wanted to make sure one plus one equaled three, not one and a half. We kept a mantra of “do no harm,” particularly when it came to delivering patient care. We were very clear on what the path forward needed to look like. The two companies operate almost 250 miles apart, so we wanted to make sure the teams knew that we weren’t going to integrate our clinical programs in the early years. The opportunity for integration was going to come more around our shared services.
Nick Barto: Messaging is important. You need to explain why you’re doing something, especially when it’s not clear to others within the organization. Communicating incorrectly can create a challenge, so we were very clear about why we were doing this—and why we were doing it now. We needed to be clear with our clinical leaders that it’s not to say we will never have clinical integration, but it needs to be bottom-up. It needs to come from our clinicians. It needs to be driven through our care organization, not through the top-down approach that you might see in the integration of some of the shared service functions, which we did in a collaborative manner.
Rich Liekweg: The other thing is that culture is critically important. We had worked with each other for ten-plus years, and our cultures were very similar. We wanted to make sure we didn’t destroy or undermine either organization’s culture. Through the integration process, we’ve actually built on the commonality of our cultures.
Drew Ungerman: For something as strategic as an integration, there’s a lot that could go wrong. There’s a lot that you’re trying to capitalize on to go right. What are the other secrets that you have found?
Nick Barto: Planning early and often is vital—and doing that within the rules of the road that come along with doing deals like this. So is establishing your baselines—including baselines for financial performance, what employee satisfaction looks like, and what patient satisfaction looks like—and really communicating that and committing to not backsliding on any of those operational issues that ultimately make us who we are.
It’s also important to stay within the rules of the road in terms of building on the teamwork. On day one, you can start the integration process by building that camaraderie, understanding what some of the hard decisions are going to be after that first day, making them quickly and decisively, and moving through them in a fair and open way.
Rich Liekweg: We set a three-year road map that had very clear deliverables and mile markers along the way. We discussed and shared that as a leadership team across the organization. At every board meeting, we update the board on how we are doing relative to the road map that we presented them on day one.
Drew Ungerman: How can leaders prevent disruption to day-to-day work during an integration like this?
Nick Barto: People need to know who’s focused on daily operations and who’s focused on integrations. We wanted to avoid backsliding, so we created an integration management office to ensure that roles were clear. We pointed out that most people in the organization needed to keep doing what they’ve been doing, which is deliver great care to our communities. We needed to keep them informed, too—we’re not doing this behind closed doors. The message from day one was: “We're doing this as a way to get better and get more scale. By doing so, we can invest more into our clinical assets and our broader care delivery network.”
Drew Ungerman: How should CEOs think about keeping their leadership teams focused when going through something as momentous as this kind of combination? How do you ensure that employees beyond the top team feel supported and engaged throughout?
Rich Liekweg: There’s no such thing as overcommunicating. Particularly with the leadership team, you must constantly make sure that you’re discussing the value of such a transaction or initiative. It needs to be tied back to the purpose and the values of the organization. And it’s not just the CEO communicating. It’s also the people leading the integration management office who are deep into specific integration work.
Then we had to create avenues to get feedback from our team members. As deliberate as we were, we recognize we may not be getting everything right. So we needed to make sure we’re hearing from all constituencies on what’s working well, what’s resonating, and where we have opportunities to improve. We used lots of communication vehicles, whether it was video, team meetings, town halls, or emails. There probably wasn’t a week that went by, particularly in the first year, where this wasn’t a topic of discussion across the organization.
Drew Ungerman: What do you think now about the ideal team resourcing and organizational structure that can really deliver on integration goals?
Rich Liekweg: I’ll give you three ingredients that have worked well for us. It starts with the executive leadership team. In our case, we were very intentional that the team would be made up of individuals from both organizations.
Number two, we stood up our own integration management office and had an executive from each organization help lead that work. That was another key ingredient: having an internal set of experts—not just leadership, but also pulling people out of operations to help lead and be a member of that integration management office.
Third was using an outside third party. McKinsey was that partner for us. McKinsey brought expertise and experiences in a variety of different organizations that complemented the work we wanted to do and the work that we were prepared for staff to do. In order to move the integration at the required pace, we needed outside help.
Nick Barto: The tools that McKinsey brought to the table—not just from within healthcare but also from organizations outside of healthcare, such as multinationals and other entities that have gone through integrations—were very helpful. We as leaders need to hold ourselves to a standard of not just being the best in healthcare but being the best at delivering financial solutions, supply chain solutions, and so forth. While it’s important to have outside advice, it’s our work to own. At the end of the day, we’re the ones that the board holds accountable.
It’s also important to identify talent gaps within the team and think about hiring from outside the organization to bring a level of expertise that we don’t have today. It’s hard in our industry to bring someone in from the outside to lead that work as an individual within the organization. Leveraging relationships is an important part of the success of any integration in terms of the credibility that you bring to the table.
Drew Ungerman: You mentioned the importance of culture. Why is culture so critical to your journey?
Rich Liekweg: Culture eats strategy, as the saying goes. As similar as the two organizations were, we wanted to create a more common culture built on the legacy values and principles of each of our organizations. We believe our 44,000 employees—44,000 caregivers—choose to be part of our organization because of our values and purpose. It was important early on that we blended the two cultures, so we worked toward identifying a common set of values. We started with the set of values each organization brought. Then we surveyed our employees to get their feedback about what resonated. From that came a new set of BJC values that look very similar to both sets of legacy values.
We then went one step further and defined a common purpose. What are we here to do as a much larger, integrated, academic healthcare system? Everything we do, as it relates to the integration work and as it relates to patient care, is with kindness in mind—with respect, with excellence, with safety, with teamwork.
Nick Barto: To Rich’s point, it’s important for everyone to see what their organization brought to the table in that purpose statement and in those values. Now we’re weaving it into the daily operations of the organization so that people can see themselves and their history in the operating plans we’re putting together to move forward together.
Drew Ungerman: What are some of the long-term objectives on your horizon? How can leaders considering a combination of this magnitude balance long-term priorities with short-term needs?
Nick Barto: One of the long-term objectives is to be better than what we both were coming into the combination. We analyzed how we can together exceed our five-year plan from a financial, patient satisfaction, and employee satisfaction point of view. Setting out those tangible goals is what we both did coming in.
We’ve developed a three-year road map that touches on technology, such as support services. We were using legacy systems, but we’re moving to a single ERP [enterprise resource planning] system. The ERP is really the backbone that enables us to build new business processes to begin to transform the organization. “Transform” is a word we continue to use—we’re transforming the processes that we use to run day-to-day operations and articulate how we can better use technology to help all of our employees, not just our clinical employees.
A long-term objective of anyone in our industry is to figure out a way to take costs out. We’re still seeing a lot of inflation, and we need to be honest about the fact that this is about reducing the total cost of care. It’s about reducing the total overhead expense that we see as an organization as we continue to fight those industry headwinds, streamline and eliminate duplication, and make sure we’re investing every dollar we can back into care, capital, and communities.
Rich Liekweg: We want to make sure that we create opportunities to reinvest in our care teams to allow them to be much more satisfied in the work they deliver and how they deliver that work across the organization. And to reinvest in the communities that we serve. We play significant roles outside the four walls of the clinical space, so it’s important that we be efficient so we can create that investment capability and continue to do what we’ve done for generations, which is to expand and create greater access points for our patients and for our communities.
Drew Ungerman: I’d love to close by asking each of you what you’re most proud of as you look back on the integration efforts and as you look forward.
Rich Liekweg: I’m most proud that we had the support of both of our boards to take this bold step. Also, that the combined team of leaders from both legacy organizations came together, laid out a road map, and are executing it as planned—maybe even ahead of plan.
We continue to perform at a very high level when it comes to quality of care and how we benchmark against our peers on employee engagement and satisfaction, on patient satisfaction, on financial performance, and our ability to continue to invest in our communities. None of those metrics slid backward, and in fact most metrics advanced. I’m very proud of our 44,000 caregivers. A lot of this integration is not occurring in the clinical environment, so a large portion of the organization has stayed focused on our purpose of delivering exceptional care.
I’m proud of how our board came together. We added eight new board members to the BJC legacy board who came from the Saint Luke’s Health System and said goodbye to some board members from BJC. The new board has come together, and if you were to experience a board meeting with them you would think this board had been together for years. I couldn’t be prouder of the governance role that they play for us.
Nick Barto: I’m most proud of our teams for delivering on our strategic priorities. As we went through this integration, we were also reestablishing a 45-year agreement with Washington University School of Medicine, which is a core part of the history of BJC. We’ve entered into a variety of joint ventures, and we’re looking to expand our children’s hospital beyond St. Louis. So to do the things that we did as a leadership team to set ourselves up for success in terms of expanding on the core operations and building on our existing relationships was really a remarkable feat.
