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Physician Leaders: piloting the ship, or going down with it?

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I’ve worked with and studied a lot of physician leaders. They have all been excellent clinicians, surgeons, and care givers. However, when tapped to lead (a clinic, department, or hospital) there is sometimes a lack of experience and skills that are needed to be an effective leader.

Trained as experts to make life-saving decisions, doctors are sometimes reluctant to listen to others’ opinions. Sometimes this is the result of a conscious decision and sometimes this is a result of an unconscious decision – which can be the result of the type of training they have experienced. Typically this trait of taking a “rely only on myself” quality is most pronounced when multi-tasking, under stress or in times of change, all of which a leader faces on a regular basis.

As we have all seen, leaders have significant impact on the individuals and teams in their organizations. This impact can be either very positive or very damaging. So, when you’re looking to promote a talented physician (and this also applies to other clinical staff as well) to a leadership role, please consider whether or not they possess the following qualities:

  • Good listener: one who can consistently listen and be open to others’ opinions and perspective. Is it “my way or the highway”? Do they always need to be right or act like they have something to prove?
  • Effective communicator: can this person talk to their peers, other leaders and subordinates with the same degree of effectiveness? Can they deliver difficult messages in a constructive manner?
  • Collaborates/relates well to others:  does she/he behave in a way that indicates a core belief that functioning as a team is a preferred and productive way to manage? Or, is it more about the individual and trying to outwork any issue or challenge that needs addressing?
  • Has a shared group vision: is there a singular agenda or is this person open to what is best for the team and organization?  Sometimes called collective thought—there needs to be a clearly defined mission, with ways to measure milestones, successes and, inevitably, failures (so you can learn from them).
  • Will lead, not dictate: ask yourself if this individual is truly a team player and willing to continue to roll up his/her sleeves and do the work and lead by example, not just sit behind a desk in their new corner office expecting the work to be done as they dictate.
  • Humble: Finally, I’ve found that being humble, open and willing to learn goes a long way. Yes, practitioners at this level have become experts in their specialty.  However, when steering a larger ship, there are new qualities, skills and tools that need to be learned and integrated into their job. Are they humble enough to realize this and to do the development work that is required?

If the clinician you’re looking to promote has at least 3 of the above qualities, then there’s a good chance they will become successful and effective leaders. We all know it takes a solid foundation of non clinical skills in order to effectively navigate the stormy waters of clinical leadership.

If you have an already promoted a leader who needs some skill development, contact us. Or if you have a practitioner who you’re thinking about promoting and have some nagging questions, contact us. Coaching for skill development is what we do. Let us help!

Are healthcare providers hearing the wake-up call?

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Sometimes the last people to know that an organization is about to hit a catastrophic iceberg are the leaders of the organization, even though they spend millions on writing strategic plans to avoid such an event.  It can be too devastating to leadership to consider that one’s oftentimes beloved institution, with a culture that has one’s own stamp on it, grown by close colleagues, is about to be threatened to its very foundation.  It can be too devastating to acknowledge that our beliefs may no longer be true, our skills may no longer be adequate, and/or our very way of life within the institution needs to change.  Adults hate change…why look into the abyss?

I’m actually worried for the hospital systems of the U.S.  I don’t think they realize that the game may be changing so radically that it may feel like they’ve hit an iceberg, regardless of the fact that they are wealthy institutions, rich in capital and knowledge.  Consider the following recently publicized facts:

I. The largest company dedicated to meeting the health and well-being needs of Medicare beneficiaries (UnitedHealthcare) and the largest retirement community in the country (The Villages) have formed an exclusive relationship designed to create “additional health benefit options and facilitate coordinated, comprehensive care” at a new patient-centered health system for Medicare consumers.

  • Threat:  The payer has hired the primary care staff, including MDs, and bypassed the traditional health system, except for specialty care which it will better control.

II. The proportion of companies with more than 20,000 employees offering High Deductibles went from 41% in 2007 to 59% in 2012. “If we’re not already at the tipping point for [consumer-directed health plans] — and we may well be — at this rate of growth, it’s coming soon,” said Sharon Cunninghis, Mercer’s U.S. business leader for health and benefits.

  • Threat:  Consumers are beginning to see the “list price” for health care and realizing what Steve Brill so adeptly revealed in “Bitter Pill”, Time Magazine:  prices are too high, and large, insular health systems, basing negotiations with payers on a “discount %” methodology, have not been paying attention to true costs.

III. Memorial Sloan Kettering Cancer Center, IBM, and WellPoint (a managed healthcare company) announced earlier this year that they are teaming to incorporate Watson, the supercomputer, into medical practice.  As “MedGadget” reported, “medical literature evolves at the blink of an eye, and it is impossible even for the most learned of physicians to keep up with all the data involved in [cancer]. It’s in fact estimated that only 20% of what the average doctor practices is evidence-based.”

  • Threat:  if Watson-like technology has the magnitude of impact that Google has had, large amounts of the bureaucratic apparatus of health care may no longer be needed.  Consider a world where the physician really isn’t the person with the answer, the computer is.  Consider how the power would transfer from the health system (who has the docs) to the patient and the payers.  I’m not sure it is possible to fully imagine the impact on the organizational design and management structure required by a health system when it’s the patient who is directing care using their mobile device.

IV. The Harvard Medical School invited David Goldhill, author of Catastrophic Care, How American Health Care Killed My Father, to speak with Ashish Jha, Professor of Health Policy and Management, Harvard School of Public Health.  Clearly, Mr. Goldhill is becoming a force for the voice of the patient in driving health care.  He believes that health systems have treated the payers, not the patient, as the customer in heath care and that they must now be made accountable to the patient.  He is not to be underestimated.  If you remember Ross Perot, you realize that one man, with a platform and a message, can indeed radically change the public debate.

  • Threat:  the threat here is that new institutions arise that really “get it”.  As the UnitedHealthcare example shows, a newly configured organization can develop a new delivery model based on consumer knowledge, price transparency, partnership with the patient and widely disseminated medical knowledge.  Wow.  Are our health systems ready for this?

These are just some of the tectonic shifts occurring on the ground and in the press.  Those who “will not see” these shifts are likely to be doomed.  Those who don’t have the fortitude to address these trends head on could be doomed.  Those who do have the courage to take on the magnitude of change could still be doomed.  And those who have the courage to take on the change and the brilliance to design the future, versus longing for the past, will not be doomed.

Advice to those who want to be part of the solution?  There are 3 changes you can make immediately that would improve the likelihood of weathering the changes to come:

  1. Start hiring from other industries… finance people, IT people, HR people, supply chain people, customer service experts, call center experts, again, you get the idea.  All roles but your core clinical ones should have a good percentage coming in from non-healthcare industries.  Service-based industries, most likely.
  2. Specialize:  put the power with the service line chief.   The challenges are just too large to take on at the global level.  Reduce the power of the central infrastructure, except where centralization is key to cost reduction (i.e. supply chain).  Hold the service line chief accountable for Triple Aim plus revenue growth and staff talent.  (For more information, read our whitepaper on Accountability in Healthcare. 
  3. Get your chargemaster out, look at it and start managing pricing seriously on a rational basis.  Develop cost models based on real costs, not RVUs.  Consumers will get the hang of this soon and the earlier your house is in order, the better it will be.

An accountable healthcare organization – it is possible!

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I was excited to read recently that the Cleveland Clinic took the radical step of eliminating their departments of medicine and surgery! In the article Cleveland Clinic’s 4 radical approaches to care integration, patient satisfaction, by Karen Cheung-Larivee, December 7, 2012, published on FierceHealthcare, Karen states that they were “rethinking the organization based on patient needs.” Radical!?

In my recent whitepaper on accountability in health care, I make the point that physician leaders are not empowered to run a Service Line, not in the sense that they have full accountability for all 5 critical goals:
“Triple Aim”
• Excellence in clinical outcomes
• Value
• Patient Satisfaction
Institutional success
• Revenue growth
• Culture that attracts and retains the very best clinicians, leaders and staff.

Most service line chiefs do not have full authority and consequent accountability for everything that happens to their patients, including inpatient services and nursing. Also, frequently, they must fight political battles with the Chief of Medicine or Chief of Surgery who manage a function rather than a cohort of patients. So the old model of a Department of Surgery and a Department of Medicine are one of the many confounding elements that make service line accountability difficult. Yet, here we have one of the most renowned healthcare institutions tearing away the old assumptions and operating under a new model.

This type of fundamental restructuring of organizations can be a game changer. It genuinely empowers leadership in the service lines to drive improved outcomes, process improvement, staff development and more, all while being able to look at the full financial impact of their decision, whether inpatient or outpatient, surgical or noninvasive.

Once organizations truly begin to rethink how they serve their patients, from the patient’s point of view, I truly believe that improving value (better outcomes at best cost) will truly be within reach. What do you think?

Our Unequal United States: Where you Live Matters

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The healthcare marketplace in the U.S. is undergoing rapid, wholesale change with no end in sight. The population continues to grow and, more importantly, age. At the same time the total amount of knowledge and capabilities that exist in the medical field is growing at an exponential rate as scientifically generated results from the laboratory are translated into new treatment protocols at an ever faster pace. The knowledge required to function as a Primary Care Physician today dwarfs that required of the previous generation of physicians.

Additionally, and regardless of the final details, the role of government will continue to grow. The scope of the government’s role will expand as implementation of the ACA (Affordable Care Act) is phased in over the next decade. Even if the ACA is repealed or significantly modified, the government’s percentage of involvement will grow as the population ages and end-of-life costs continue to be the majority of an individual’s medical lifetime cost.

Lastly, we are already facing staffing issues in the U.S. with vast discrepancies of accessibility to physicians based on where you live. According to the Association of American Medical Colleges, there were 744,224 licensed and active physicians in the U.S. in 2011. Of those, 208,802 were aged 60 or older. At the same time there were 80,279 enrolled in the 137 accredited U.S. medical schools. Assuming no attrition, medical school graduates transitioning into their clinical residency (3 to 7 years) will average 20,070 per year, fewer than those retiring. Thus, a diminishing pool of physicians will be serving a dramatically growing population as the uninsured population of the U.S. (40+ Million) is absorbed into the covered population under the ACA.

Change in this marketplace is unavoidable unless we find a way to suspend the economic theory (law?) of supply and demand. As my IT friends like to joke about their projects: pick any two – (high) quality, (low) cost, or timeliness. Which of us would accept poor quality, delayed access or increased costs regarding our personal access to healthcare?

To me, the plain but not simple answer involves seriously addressing the supply side of the equation. But creating more MDs more rapidly is viable only in the longer term and probably only after medical schools have drastically revamped their existing educational model.

Demand can be somewhat mitigated by the transfer of tasks from MDs to non MD clinicians, by increasing MD efficiency through the careful application of new technologies and by executing against the universally discussed focus on creating and maintaining health as opposed to focusing on the treatment of illness.

Each potential solution, or combination of solutions, presents its own challenges. And it may be that we must do them all to prevent either an access crisis or a fiscal crisis.

Big Data: Becoming Truly Patient-Centered

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I was recently working with one of my clients at a large, highly respected academic medical center. We started chatting about the scope of their data warehouse project and I was struck by the lack of focus on the patient and what the institution needed to put in place to better serve the patient. Not uncommon in what I run across in healthcare today.

For many years, the provider market has touted the need to become patient-centric…versus its historically provider-centric model. Yet, as with many new concepts that take years to be embraced, it is not always clear how a new paradigm impacts operational work.  In the case of patient-centeredness, does this new concept have any impact for data warehousing? It should, but it won’t if leaders of these projects don’t think beyond their normal paradigm.

What is a Patient-Centered Warehouse?

Being patient-centered for many warehouse builders translates to a very simple notion…the patient identifier is central to gathering myriads of data elements. Most of these data elements, however, are gathered inside the footprint of the institution where the warehouse is being built, typically, a hospital system that includes ambulatory and inpatient settings.

A truly patient-centered warehouse would have an entirely different perspective…it would hold the life information of the patient, including dietary, dental and non-system providers, perhaps dermatologists, clinics, pharmacy purchases and more. It would extend far beyond the walls of the traditional hospital system.

To treat the “whole” patient, we need to have the “whole picture”. The challenge, anyone would say, is that we can’t always get the data. There are privacy concerns, cross institutional questions and technical challenges.  However, check out the “Consolidated Wealth Reporting” websites. I know that Fidelity Investments is launching one. Here is a link to one from Fortress Financial Services, LLC:  http://www.fortress-llc.com/Our-Consolidated-Wealth-Reporting-Service.9.htm . The financial services business has solved the challenge by having the consumer give access to whatever information they choose to consolidate.

A similar model is quite possible in healthcare. We have to develop the tools and technology, but a truly patient-centered approach to gathering and utilizing patient information is well within reach using current technology. What a healthcare system truly needs to embrace are technologists who come from other industries and who can accelerate the innovation that healthcare so desperately needs.