Richard Afable, MD, MPH, is the president and CEO of Hoag Memorial Hospital Presbyterian, a two-hospital system based in Newport Beach, Calif. Before his current position, Dr. Afable spent time in leadership positions with Catholic Health East and Preferred Physician Partners, along with 10 years in private practice in Chicago where he specialized in internal medicine and geriatrics. Here, Dr. Afable shares insight on the value of physician executives, evolution in the healthcare industry and how he avoids burnout.
Q: What are some of the benefits of a hospital system being run by a physician executive opposed to a leader strictly trained in business? How does your clinical background come into play and reinforce your leadership?
Dr. Richard Afable: Mine has been an atypical career path, which is not unusual for physician executives in a health system or hospital. Historically, physician executives have been very prominent in physician-led organizations for more than a century — systems like Mayo Clinic, Cleveland Clinic and Geisinger Health System. Hospitals, on the other hand, have traditionally not been predisposed to promoting physician executives, especially since the mid-1960s with the onset of Medicare and big business arrived in healthcare. This is changing, however. There is a transition occurring today in which we're beginning to see more physician and clinician leaders of hospitals and health systems all around country.
As a physician executive, my leadership style is has been focused on patients and patient care because that's where my roots are. I've been in healthcare for 30 years, and most of that time was spent in direct care of patients. My leadership style is patient-centered, clinically-focused and operationally designed around improving care and care processes.
Q: How does your clinical background influence your relationship with physicians?
Dr. Afable: In the traditional sense, hospital CEOs are usually non-clinicians. In a setting in which the CEO is a physician executive, physicians are dealing with another clinician with knowledge of medicine and the culture of caring for patients. There are going to be different discussions there — for better or for worse.
Physicians may approach a non-clinician hospital administrator with a certain rationale on why they needed a program, and that manager would then make the decision on financial or resource grounds. Now when they're talking to a physician leader, the decision-making process would typically be more broad-based. It's not predominantly based on financial or operational requirements. Clinical appropriateness can play a much more prominent role. Yes, I may understand the physicians' perspective in these discussions, but I might also be much more discerning with the clinical impact on outcomes and thus might be "tougher" to convince. It can go both ways.
Q: How does Hoag stay connected with the community and remain a preferred provider? What advice would you offer to hospital leaders trying to strengthen their community ties?
Dr. Afable: Hoag was founded 58 years ago by the community. It started as a community hospital for a relatively small community of approximately 200,000 people. Orange County, Calif., now has more than 3 million people and Hoag is the largest independent provider of care. Most importantly, we are a community-based non-profit organization that exists for the community and is operated by the community. We have a community-based board that governs and directs this organization. Our ties to the community are innate, they're in our DNA.
As a faith-based organization, we also provide direct community benefit through a form of "tithing." We dedicate at least 10 percent of our operating income back to the community in direct community benefit. We reach out to the community with free clinics, resource centers for Alzheimer's patients, direct support for senior transportation, medical care for local schools, parish nursing programs and mental health services. We are much more than a local hospital in our community.
Q: Can you share a bit about Hoag's strategic planning? How does that process generally work?
Dr. Afable: We have developed a very comprehensive and efficient strategic planning process. Yes, we do annually plan and budget like most organizations. In addition, we have ongoing education of governance, medical staff and management to keep the knowledge base fresh and up-to-date. We roll up our annual planning into comprehensive, high-level 3-year plans that try to predict our future while maintaining flexibility. Right now, we're in the middle of our second year of one of these 3-year strategic plan cycles. We'll begin developing the next 3-year plan in Jan. 2012.
Q: You have extensive background in healthcare. How would you say healthcare management has changed since you first began working? More specifically, how do you think healthcare reform has changed the role of the hospital CEO?
Dr. Afable: It's been clear to me for the 10-plus years I've been functioning as a health system executive that healthcare is changing in an evolutionary way. It's evolving into a much more care-focused and delivery-focused "business," if you will. It's been clear that this evolution and transformation was irrefutable. I recognized early on that there would be a need for leadership by individuals with deep knowledge of clinical medicine and care. That's where the field is going. I think we're seeing that evolution taking hold right now. There's a lot of buzz around accountable care organizations, but I like to talk about the A and the C much more than the O in the acronym. The whole concept of accountable care — responsibility, accountability, transparency, outcomes — is a centerpiece to how and why good healthcare care is delivered. Today’s healthcare reform is just the further manifestation of the evolution that has been taking place over the past 10 years.
Healthcare today is more about care and less about assets. Health information technology and the transportability of information allows for this evolution to take full effect. For me, deep knowledge of actual care processes and experience in responsibility for the outcomes of care can provide a distinct and valuable advantage. And no one is more responsible for outcomes of care in our facilities than the hospital CEO.
Q: How do you avoid burnout? What types of practices do you think can reduce a burnt-out workplace culture?
Dr. Afable: I'm a big believer that passion and meaning in work can help to supersede worker burnout. I think people burn out when they're bored or feel a lack of meaning in their work. Being able to say, "I can't wait to go to work on Monday" is a tremendous motivator. We all need to work out, eat well, get enough sleep and have good work-life balance. However, for me, you avoid burnout by igniting passion. And I try to make sure all 5,300 Hoag employees know what we're accomplishing and the important purpose here.
Q: Any exciting plans or goals for Hoag in the next year?
Dr. Afable: We are working hard to prove a hypothesis: that organizations like Hoag — traditional, community hospitals with a voluntary medical staff — can produce clinical outcomes and operational efficiencies equivalent to or better than the most integrated health systems in the U.S. Those systems are integrated by design; we are not. There are probably a few hundred integrated systems across the country; there are more than 4,000 hospitals and health systems that look like Hoag. We're working hard to show that non-integrated systems can create valuable and credible results that rival the best anywhere.
How are we hoping to do this? Mostly by creating sustainable, mutually beneficial physician alignment. Not only between doctors and hospitals but also between physicians and physicians. And not employment; alignment. You need four elements of alignment to be successful: clinical, financial, operational and vocational. I find that employment is oftentimes light on the operational and vocational side. When you get those four elements in sync between a hospital and physician or physician group, the results can be remarkable.
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Q: What are some of the benefits of a hospital system being run by a physician executive opposed to a leader strictly trained in business? How does your clinical background come into play and reinforce your leadership?
Dr. Richard Afable: Mine has been an atypical career path, which is not unusual for physician executives in a health system or hospital. Historically, physician executives have been very prominent in physician-led organizations for more than a century — systems like Mayo Clinic, Cleveland Clinic and Geisinger Health System. Hospitals, on the other hand, have traditionally not been predisposed to promoting physician executives, especially since the mid-1960s with the onset of Medicare and big business arrived in healthcare. This is changing, however. There is a transition occurring today in which we're beginning to see more physician and clinician leaders of hospitals and health systems all around country.
As a physician executive, my leadership style is has been focused on patients and patient care because that's where my roots are. I've been in healthcare for 30 years, and most of that time was spent in direct care of patients. My leadership style is patient-centered, clinically-focused and operationally designed around improving care and care processes.
Q: How does your clinical background influence your relationship with physicians?
Dr. Afable: In the traditional sense, hospital CEOs are usually non-clinicians. In a setting in which the CEO is a physician executive, physicians are dealing with another clinician with knowledge of medicine and the culture of caring for patients. There are going to be different discussions there — for better or for worse.
Physicians may approach a non-clinician hospital administrator with a certain rationale on why they needed a program, and that manager would then make the decision on financial or resource grounds. Now when they're talking to a physician leader, the decision-making process would typically be more broad-based. It's not predominantly based on financial or operational requirements. Clinical appropriateness can play a much more prominent role. Yes, I may understand the physicians' perspective in these discussions, but I might also be much more discerning with the clinical impact on outcomes and thus might be "tougher" to convince. It can go both ways.
Q: How does Hoag stay connected with the community and remain a preferred provider? What advice would you offer to hospital leaders trying to strengthen their community ties?
Dr. Afable: Hoag was founded 58 years ago by the community. It started as a community hospital for a relatively small community of approximately 200,000 people. Orange County, Calif., now has more than 3 million people and Hoag is the largest independent provider of care. Most importantly, we are a community-based non-profit organization that exists for the community and is operated by the community. We have a community-based board that governs and directs this organization. Our ties to the community are innate, they're in our DNA.
As a faith-based organization, we also provide direct community benefit through a form of "tithing." We dedicate at least 10 percent of our operating income back to the community in direct community benefit. We reach out to the community with free clinics, resource centers for Alzheimer's patients, direct support for senior transportation, medical care for local schools, parish nursing programs and mental health services. We are much more than a local hospital in our community.
Q: Can you share a bit about Hoag's strategic planning? How does that process generally work?
Dr. Afable: We have developed a very comprehensive and efficient strategic planning process. Yes, we do annually plan and budget like most organizations. In addition, we have ongoing education of governance, medical staff and management to keep the knowledge base fresh and up-to-date. We roll up our annual planning into comprehensive, high-level 3-year plans that try to predict our future while maintaining flexibility. Right now, we're in the middle of our second year of one of these 3-year strategic plan cycles. We'll begin developing the next 3-year plan in Jan. 2012.
Q: You have extensive background in healthcare. How would you say healthcare management has changed since you first began working? More specifically, how do you think healthcare reform has changed the role of the hospital CEO?
Dr. Afable: It's been clear to me for the 10-plus years I've been functioning as a health system executive that healthcare is changing in an evolutionary way. It's evolving into a much more care-focused and delivery-focused "business," if you will. It's been clear that this evolution and transformation was irrefutable. I recognized early on that there would be a need for leadership by individuals with deep knowledge of clinical medicine and care. That's where the field is going. I think we're seeing that evolution taking hold right now. There's a lot of buzz around accountable care organizations, but I like to talk about the A and the C much more than the O in the acronym. The whole concept of accountable care — responsibility, accountability, transparency, outcomes — is a centerpiece to how and why good healthcare care is delivered. Today’s healthcare reform is just the further manifestation of the evolution that has been taking place over the past 10 years.
Healthcare today is more about care and less about assets. Health information technology and the transportability of information allows for this evolution to take full effect. For me, deep knowledge of actual care processes and experience in responsibility for the outcomes of care can provide a distinct and valuable advantage. And no one is more responsible for outcomes of care in our facilities than the hospital CEO.
Q: How do you avoid burnout? What types of practices do you think can reduce a burnt-out workplace culture?
Dr. Afable: I'm a big believer that passion and meaning in work can help to supersede worker burnout. I think people burn out when they're bored or feel a lack of meaning in their work. Being able to say, "I can't wait to go to work on Monday" is a tremendous motivator. We all need to work out, eat well, get enough sleep and have good work-life balance. However, for me, you avoid burnout by igniting passion. And I try to make sure all 5,300 Hoag employees know what we're accomplishing and the important purpose here.
Q: Any exciting plans or goals for Hoag in the next year?
Dr. Afable: We are working hard to prove a hypothesis: that organizations like Hoag — traditional, community hospitals with a voluntary medical staff — can produce clinical outcomes and operational efficiencies equivalent to or better than the most integrated health systems in the U.S. Those systems are integrated by design; we are not. There are probably a few hundred integrated systems across the country; there are more than 4,000 hospitals and health systems that look like Hoag. We're working hard to show that non-integrated systems can create valuable and credible results that rival the best anywhere.
How are we hoping to do this? Mostly by creating sustainable, mutually beneficial physician alignment. Not only between doctors and hospitals but also between physicians and physicians. And not employment; alignment. You need four elements of alignment to be successful: clinical, financial, operational and vocational. I find that employment is oftentimes light on the operational and vocational side. When you get those four elements in sync between a hospital and physician or physician group, the results can be remarkable.
Related Articles on Hospital Leadership:
9 Leading Hospital CEOs Share Advice for Fellow Hospital Leaders
Multi-Generational Leadership: How to Bridge Gaps in Age and Understanding
Quint Studer: One Simple, Powerful Way to Improve Communication at Your Hospital