What Hospitals Are Doing

            Clinical microsystems are the key to effective, efficient and safe performance, but failure to recognize the strategic value of human resources in healthcare systems has led to persistently high turnover, which makes building stable, effective teams difficult to impossible. As hospitals and healthcare systems recognize the need to improve (and prove) the value of services rendered, some have started making steps to address these issues. In April 2014, the American Hospital Association published a report[1] summarizing surveys of some 1100 executives, primarily from large hospital systems, followed by detailed interviews of 25 executives from selected systems. The report is designed to show the sorts of initiatives that large organizations are undertaking to transition from volume-based reimbursement to value-based reimbursement, recognizing that these buzz-words cover a lot of detail complexity.

            The two issues addressed that I want to consider in more detail are 1) “How are traditional roles, such as chief financial officer, chief medical officer, and chief nursing officer, evolving in response to changing business needs?”; and 2) “How might physician and nurse leaders be tapped to play a larger role in the future?”

            The authors started by asking “What are the key strategic priorities over the next three years?” Not surprisingly, five of the eight involved ways to capture either more business or more money from the same book of business, and one involved better use of information technology. 39% said a key goal was to “adopt evidence-based practices to improve quality and patient safety,” but only 15% said a key goal was to improve “employee and physician training, engagement, and leadership skills.” The authors asked what the major barriers to achieving strategic objectives were. A quarter identified “physician buy-in and engagement,” and “financial constraints,” and 15% identified “organizational barriers to collaboration,” “lack of talent/skill sets for key roles,” and “cultural impediments with the organization.”

            They next asked what gaps the organization needed to fill in order to execute the strategic goals. 54% said they needed expertise in non-traditional health partnerships, 48% needed community and population health management experience, 41% needed expertise in change management and leading transformational change, and 34% needed innovative and creative thinking.  Bringing up the rear were service and patient focus (9%), internal relationship building, (6%), clinical experience, (6%), and quality/patient safety experience, (5%).

            Organizations are expanding the role of existing executives and adding new executives. One question, though, was who was always involved in regular decision making. The CEO was involved in 73%, the CFO in 66%, the COO in 55%, the CMO in 53%, the CNO in 47%. When they asked who was involved in decision making when necessary by topic, the CMO involvement fell to 40%, and the CNO stayed about the same at 49%.

            These executives were fairly consistent in identifying the skills they needed their people to have. The most critical were critical/strategic planning (94%), innovative thinking/creativity (88%), and transformational change/change management (83%). In the second tier were service and patient focus (81%) and quality/safety expertise (71%).

            So where are organizations going to find people with these skill sets, particularly given the highly regulated nature of the health care enterprise?

            Hospital and health care system leadership once was viewed largely as the purview of non-physician administrators and, even more recently, administrators have been seen as the primary drivers of strategy and change. That perspective is quickly evolving, as hospitals and care systems alter care delivery models, evaluate clinical design and reorganize into service lines. In this changing environment, clinical thinking must be integrated into operational decisions. “It will be critical for clinical leaders to be involved at the top so that change can occur more quickly,” one executive noted.

            Given the growing cadre of physician and nurse leaders, some health care organizations offer programs targeted specifically to clinical leaders. Physician executive academies, mini-physician-MBA programs, skill development boot camps, and physician leadership universities are a few of the examples identified during the interviews. Many of these programs incorporate coursework and team projects and cover negotiation, basic finance, team work dynamics, communication, leading other physicians, trends in health care, and technical and soft skills. Many health care organizations also have established physician and nurse mentorship programs, which pair new clinical executives with experienced leaders to provide them with a resource to navigate relationships and answer questions.

            Other leadership development programs bring together clinical leaders with administrative and business executives, with the goal of promoting integrated thinking and mutual learning, or target particular development needs, such as change management, employee engagement, service excellence and lean management techniques. One health care system, for example, sends 20 to 30 people at a time from all levels of the organization to an intermediate improvement science program. Over the past several years, this initiative has created a small army of improvement gurus scattered throughout the organization.

            The report does not point out some of the contradictions inherent in the responses to the questions asked, but I think those contradictions represent the real challenges facing these organizations.  For instance, 39% identified improving quality and patient safety as a strategic goal, but only 15% identified training and leadership development for physicians and nurses. I wonder how these executives expect to achieve their goals?  Perhaps by fiat, but that is doomed to fail—if decree would get it done, there would not be an issue. As I have argued in a number of articles, the only way to improve patient quality and safety is by developing empowered teams of clinicians, both nurses and doctors, working at the bedside. To be sure, these teams need administrative support, too, but administration alone cannot get it done.

            The second contradiction is that organizations say they want clinician/physician leadership, despite the fact that their current CMO and CNO are involved less than half the time in decision making now, but identify lack of physician engagement as a barrier. Even those organizations investing resources in leadership development are, in my view, operating from a mistaken premise. When I read the quote included above, I get the sense that their goal is to make good physicians into adequate administrators. To me this is the same as Henry Higgins’ misogynist lament.[2] I don’t think it is helpful to take the time of good clinicians and try to make them administrators, any more than it would be helpful to take good administrators and try to make clinicians out of them. The skills sets of either group take time, training, and experience to hone and develop. The proper goal for an organization, as I see it, is to maximize the ability of each to contribute to the team effort.

            Previously, I have talked about teamwork and what sort of game are we playing. Too often, I fear, everyone is trying to play football, with one person calling the plays and all the other people using their skills to make the play succeed. But clinical reality is much messier than this—multiple people, including the patient, call different plays, often at the same time. I think baseball is a better, albeit perhaps anachronistic, metaphor.  The pitcher is important, but so are each fielder and batter. A good management team can enable the player to attain his full potential, but management does not play the game, and no amount of managerial wisdom can overcome a lack of talent on the field.

            If physicians are to be involved in a meaningful way that is congruent with their skills, training, and experience, it is incumbent upon administrators to construct systems designed to facilitate this involvement. This does not mean that physicians need to be at every meeting, nor does it mean that physicians should just tell administrators what to do. I contend that all physicians are very good at two important executive functions. First, they are all overly busy, and prefer it that way. However, this means they are all quite good at prioritizing. I think this can be leveraged in healthcare systems by getting them involved in setting priorities and goals for things they know and care about, like improving patient care and safety. I suspect one short meeting of all the general surgeons, for example, who result in consensus about the three most pressing issues in the OR.

            I would not recommend asking the surgeons to fix the issues. Instead, the administrative team should do its investigation of the various processes involved and determine what options exist for improving the problems without undue disruption or expense elsewhere. In most cases, at least a couple of viable options will develop.

            Once the options are developed, I would call the general surgeons back together for another short meeting and present the options and ask them to pick the one that made the most sense to them. This takes advantage of the physician’s other key executive function—the ability to make decisions quickly and with limited information, and live with the consequences.

            So what is the outcome of such a process?  The surgeons are happy because they identified the problem and the solution. Management is happy because the solution chosen was crafted by them as being actually workable and effective.  Win-win.

            From a large organizational perspective, such solutions may seem to “micro” oriented and therefore impractical, but I believe the principles are solid and can be used at every level. Ideally, the CMO would be bilingual—able to speak the language of management to management, and the language of medicine to the physicians, and serve to translate any gaps. Like any good translator, he/she might have to discuss some of the hidden meanings of the words to make sure the right word was chosen for the translation. But I would also contend that to be effective with the doctors, his/her primary language is going to have to be medicine.

            What about the skill sets identified as being critical for achieving the organization’s strategic priorities?  I think physicians by training and experience are quite good at two of the three:  creative thinking and transformational change. Practicing medicine is a constant process of incorporating new ideas, rejecting old ideas, and solving problems for which there is no consensus. (I don’t think physicians are particularly suited to strategic thinking—usually the time frame for decisions is short, whereas the timeframe for real strategic thinking is long term. But many physicians’ time frame is longer than many administrators think.) And, of course, I think physicians are good at patient focus and do pay attention to quality and safety, although they tend to do so retail, not with a systems perspective.

            If doctors represent an available pool of talent that can check off four of the five critical skills, why are so few involved presently? Maybe the 15% who think their physicians are not engaged are correct, but maybe the problem is that few organizations try to engage physicians in ways that make sense to the doctor and build on the skills sets most of them progress. The challenge from both sides of the divide is to recognize that those organizations that value the unique contributions of both groups to the care of patients are those that will prosper and succeed for the long term, to the benefit of patients as well as to the organizations.

22 September 2014


[1] Health Research & Educational Trust. (2014, April). Building a leadership team for the health care organization of the future. Chicago, IL: Health Research & Educational Trust. Accessed 20 July 2014 at www.hpoe.org.

[2]  Lerner, Alan J., and Loewe, Frederick. My Fair Lady. (1956). “A Hymn to Him,” which includes the refrain: “Why can’t a woman be more like a man?” In gender neutral language, Henry is really complaining that Eliza Doolittle is not like him, and some hospital administrators seem to want doctors who are “like them,” not like doctors.

Further Reading

Clinical Integration 2015:  A Hospital Perspective
Health care organizations now assume "clinical integration" is necessary for economic survival, but the FTC continues to enforce antitrust actions blocking mergers and acquisitions.  Furthermore, clinical integration usually means different things to hospitals and physicians.  In this article I consider some immediate steps that can be done without legal complications to improve patient care and save money.  All that is really required is a change in our mental models.

Challenges to Achieving the IOM Attributes of a High-Quality Healthcare System
Most people agree the Institute of Medicine's (IOM) description of the attributes of a high quality healthcare system are appropriate and worthy of trying to achieve.  But it has turned out to be quite difficult to make progress.

The Practicing Physician and Medicare