Organizing for Success—Another Viewpoint
I have been arguing that successful medical organizations will find effective ways to integrate clinical and business perspectives into a patient-centered whole. Recently, Dave Chase has posted an article on Forbes.com, where he outlines some of the same points from a different perspective. He starts by commenting on an article President Obama recently published in JAMA, but then turns to a survey done by athenahealth and poses a key question.
“In any rational context, the vast majority of hospitalizations should be considered an abject failure. They reflect a failure upstream to prevent and better manage disease. However, perverse incentives have put hospital CEOs in the odd position of being rewarded like a hotel GM–the more beds filled, the better. This has created an opioid-like addiction to filling beds and overuse… The key difference I see when interviewing physicians for my writing and in the filming for The Big Heist is what drives the medical culture of a healthcare organization. With hospital-employed physicians, they are driven by their management to cut, scan, prescribe and hospitalize. After all, that’s what has driven financial rewards historically. The administration doesn’t have to leave the D.C. area to see the contrast with an organization (Privia) purpose-built for population health. In contrast to hospital-based physicians, Privia’s physicians see hospitalizations as something to be avoided or minimized.”
When turning to the athenahealth survey, he noted key findings as only 20% of physicians responding to the survey met the criteria for engagement. But in physician-led organizations it was 32% compared to 8% when it was not a physician-led organization. When physicians owned their own practice, 32% were engaged, compared to 17% for medical groups owned by health systems and 14% for employed physicians.
Mr. Chase thought there were three drivers of engagement. First was satisfaction with leadership.
“While less than half of physicians are satisfied or very satisfied with leadership overall, 74% of engaged physicians reported being very satisfied with leadership. Specifically, physicians look for high-quality physician leaders who communicate, empathize and demonstrate a high level of expertise.”
Secondly, there must be trust between the physicians and non-physician executives.
“Over one-third of respondents noted communication skills are a necessary attribute of a strong leader. Physicians not only want transparency from the top down, they want a two-way feedback loop that ensures their voices at the front line are heard by those setting the organization’s strategic direction. Physicians trust leaders who clearly articulate an organization’s vision and develop a plan to support this vision, without sacrificing employee satisfaction.”
Lastly, successful organizations have intentional work place design.
“When physicians feel that they have a workplace environment that enables them to focus on what they do best–deliver high-quality care to patients. They are engaged at almost four times the level of the physician sample overall. Aligning workplace design with physician workflows optimizes performance, reduces burnout and improves the quality of patient care. Additionally, creating an environment of collegiality among physicians enhances peer-to-peer relationships, improves communication with patients, strengthens the referral networks and leads to a more engaged workforce.”
While these items seem basic and fairly intuitive, they are clearly hard to find in practice. The first two items are the basic thesis of my entire effort—physicians (and nurses) have to have effective involvement at both strategic and operational levels of the organization in order to have engagement, and engagement is crucial for success. Many years ago, when “managed care” was the rage, I was involved in discussions with the non-physician executives at my local hospital about cost controls. They were focused on big ticket items like expensive antibiotics or expensive patients such as those with acute leukemia on chemotherapy. As it happened, my group had admitted about 77,000 patients to the hospital the previous year and at the time, the hospital was charging $100 for a CBC. (They could not tell me how much it really cost, because no one had thought it worthwhile to figure that out.) I pointed out that if the doctors ordered one less CBC per admission, then charges would drop by $7.7 million—and patient care would not likely have suffered at all. The amount was greater than that spent on patients with acute leukemia and those treated with the expensive antibiotic under review.
The third point, constructing the clinical microsystem and the issue of system resiliency, I have discussed several times. It is interesting that a non-physician emphasized collegiality. The one thing from the “good old days” that I miss is the notion of collegiality. A few of us old-timers still talk about clinical issues, but, I think it is something we should set about re-creating. Collegiality builds trust, and trust is necessary to enable physicians to decide which test to skip so they can save money for someone else.
13 July 2016
 Chase, Dave. Study Shows Doctor Engagement Critical for Obama to Reach His Health Care Reform Goals. 12 July 2016. Accessed same day at
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