The challenge
For most healthcare leaders, reform has focused on the implications of changes in payment models. Yet the objectives outlined in the Triple Aim require a significant redefinition in the way frontline personnel must work together to deliver service. No formulas, mandates or policy changes from outside the organization can determine the best way to redefine these relationships. There may be several exemplary models of organizations that have successfully cracked this nut, but typically these models are not transportable to different organization cultures.
The responsibility to reframe these critical relationships rests upon the shoulders of hospital CEOs to determine who the critical internal and external stakeholders are, to redefine what those relationships should be and to outline the strategy and tactics to move from the current state to the new one. At center stage are physicians, most of whom must learn to work in a more collaborative environment than they are accustomed to and where the work they have been trained to perform must often be distributed to others.
At the heart of the matter, most physicians are skeptical that healthcare reform will help them improve their ability to serve patients. An informal survey of physicians completed in May 2012 by the Doctor Patient Medical Association Foundation indicates that 83 percent of respondents said that changes in policy "makes me think about quitting." Ninety percent responded that they feel the healthcare system is on the wrong track. Interestingly, when asked, "Who is most likely to improve the problems in medicine?" 80 percent of the respondents believed that physicians and medical professionals held the solutions. In short, physicians do not like the direction healthcare is moving, and they feel they are the only ones who can properly reframe how healthcare is delivered.
The key for the successful transformation to the new models of care will be the manner in which CEOs use the capabilities of physicians to accomplish this work. Unfortunately, for both parties, the perceived quality of relationship between hospitals and physicians is low. A PricewaterhouseCoopers 2010 report, "From Courtship to Marriage: Why Health Reform is Driving Physicians and Hospitals Together" delves into the challenges of the hospital-physician relationship. When asked whether they trust hospitals, 20 percent of physicians surveyed said "no" and 57 percent said "sometimes."
Behind the curtain
In our work with physician leaders, we have often found them at the surface to be skeptical of hospital leadership. They believe they themselves have become replaceable commodities, not appreciated for their unique talent and the time and devotion to the profession. They believe they have little influence over the practices of the institutions they serve. They believe that healthcare administrators do not understand the complexities of their roles and see them as complaining when bringing up issues. Many physicians believe that they work in systems for which they can see no other logic than being squeezed to serve the financial interests of the larger healthcare systems of which they must be a part.
CEOs often view physicians as incapable of seeing the larger picture — unable to appreciate the complexities and challenges of running an organization. Administrators may see physicians as reluctant to look at their work with a different set of eyes. They may see physicians as naïve and self-serving, rigid and unwilling to move out of their parochial perspectives.
Both groups want something appreciably more from their relationships but appear to be unsuccessful in building mutual trust and creating more effective organizations to get what each both desperately want. The reality is that physicians and administrators working together must forge the path forward.
Peeling back the curtain, it becomes obvious that both groups must rely on one another to work through these adaptive issues in more effective ways. Both have the motivation to achieve better outcomes, yet neither side consistently knows how to capture the passion and capability of the other. This tragic set of circumstances can be overcome through some consistent leadership practices.
Building physician engagement
Healthcare administrators who consistently use five questions to guide the way they work with physicians will find it easier to build more powerful physician engagement necessary to create and implement more effective models of care delivery. The answers to these questions help create effective physician/administrator relationships during times of ambiguity and relentless change.
1. What do you want your physicians to do?
In far too many cases, senior healthcare administrators are concerned with controlling policy or providing narrow roles for their physician leaders. Physicians are consequently suspect of the intentions of the CEOs and administrators and feel that they are simply being used for some lesser purpose. Physicians will be more highly engaged if they believe their voices will be actively included on the substantive issues. Asking physicians to address and subsequently holding them accountable for the solutions of the more important organization challenges creates higher levels of transparency, a realization that there may be no single solution, and sends a message that the senior leader values physician input and does not see them as a replaceable commodity.
2. Do they know how to do the work?
Physicians are problem solvers on steroids. They are paid to see a patient and listen to the malady, diagnose the situation and determine a remedy in a matter of minutes. Typically no one has trained them how to deal with complex organization issues that require higher levels of finance, strategy, leadership, etc., that have been so much a part of the most administrator advanced education and daily experience. When the two stakeholders come together, each speaks a different language.
Rather than complaining that physicians "don't get it," it is more helpful to provide them with substantive education around core business skills so they can better understand the administrative challenges of running the organization and more effectively use their medical backgrounds to help solve them. Physicians need to understand the basics of strategy, leadership, finance and organizational development.
3. Do they have the resources to do the work?
Typically, physicians receive little financial reward for participation in leadership and organization improvement efforts. As a result, physicians shoehorn these activities. If CEOs are serious in their expectations that physicians are to make a significant difference, then the organization must make the space for them to do the work. It must demonstrate that leadership and strategic work are legitimate and important parts of their jobs and valued by the organization. Physicians must have the quality time to devote to this work and to receive recognition for its accomplishment.
4. Are physicians motivated to do the work?
Historically although physicians may have had the title of leader, in fact their primary focus has been the day-to-day management of their departments or clinics. This requires dealing with issues of scheduling, conflicts between people, operational efficiencies, etc. As a result, many physicians believe that leadership means dealing with the things no one else really wants to address or being thrown in the midst of unwinnable controversies. Because they see little positive gain by taking on the role, many capable physicians avoid taking on the leadership work.
Hospital CEOs need to help physicians more clearly understand the positive impact their leadership can have on more important issues, such as patient care, organization effectiveness and morale. In this manner, physicians can leverage their knowledge for the greater good and effectively address the higher strategic issues.
5. How will CEOs know they have been effective?
Engaging physicians is challenging work. It is helpful for CEOs to understand the benefits and the outcomes they want to achieve before they start the process. Being clear about the positive impact of better physician engagement in the change process is a critical step in shaping the message to physicians.
Historically most healthcare change initiatives have been perceived as win/lose situations — physicians typically perceiving that they have received the short end of the stick. The response to these five questions can streamline communication and execution and simplify the process of building relationships with this critical stakeholder group.
Ralph Jacobson is founder and principal of The Leader’s Toolbox and author of "Leading for a Change: How to Master the Five Challenges Faced by Every Leader." He is also a faculty member of the Physician's Leadership College. He can be reached at theleaderstoolbox.com.
More Articles on Physician Engagement:
Physician-Hospital Alignment: One Size Doesn't Fit All
Hospital Physician Engagement Still High, But Less Than in 2010
Physician Engagement in Value-Based Purchasing: 4 Hospital Leaders' Thoughts