As healthcare in America transitions toward clinically integrated networks financially responsible for providing coordinated care, a critical element for health system success will be the level of true integration with physicians.
While the importance of this is easy to understand, achieving it is quite challenging and requires commitment by health system leadership to building physician-led enterprises, according to Carson Dye, senior partner at Witt/Kieffer and co-author of the new book, "Developing Physician Leaders for Successful Clinical Integration" (2013, Health Administration Press). Mr. Dye wrote the book along with Jacque Sokolov, MD, chairman and CEO of SSB Solutions, a healthcare management, development and investment firm.
Recently Mr. Dye sat down with Becker's Hospital Review to discuss the book and best practices for developing physician leadership in healthcare organizations.
Question: Your book begins by arguing that being physician-led is a good thing, but often, healthcare executives disagree on what exactly "physician led" means. How would you define a physician-led healthcare organization?
Carson Dye: Physician-led organizations are characterized by an active and sincere desire of the leaders of the organization to have physicians actively involved in policymaking and strategy setting. It means that in many different ways, physicians play a continuous leadership role in the dynamic changes that occur in organizations. Note that it does not mean that organizations must have a physician CEO, COO or even full-time physician managers or leaders. But the physicians who work within physician-led organizations are involved in knowing and helping to shape organizational strategy and tactics. The ways in which organizations are — or become — physician led vary greatly. The tactics range from use of the Mayo dyad model of leadership to having paid administrative physicians serving in leadership and management jobs in the organization.
In our book, we suggest that the nature of being physician led is often contingent upon:
The type of organization. The answers will vary from organizations that are made up entirely of employed physicians to those that still have a large number of independent physicians. Physician leadership is different in an academic medical center than it is in a smaller rural hospital. In many small rural organizations, the only physicians in the region are those who are fully engaged in full-time clinical practice, and their leadership activities are quite part-time; an academic medical center will often have a physician CEO and full-time physician chairs who drive much of the activity of the entire organization. Both types of organizations could be viewed as physician-led.
The type of issue confronted. The role of physician leadership will also differ according to the types of issues that the organization faces — for example, is the organization losing money and facing serious financial challenges, or is it facing clinical quality problems?
The emphasis on clinical integration. If one of the key strategies of the organization is clinical integration, then physician leadership is critical.
The history of the organization and its medical staff. If the organization has long had a well-developed and highly involved medical staff, it likely has a larger number of physician leaders.
The attitude of the organization's board and senior leadership toward physician involvement. Organizations that have long put a premium on actively involving physicians in setting strategy and making decisions are far down the road toward having strong physician leadership. Yet some organizations still have a view of physicians as being merely producers of the product, so they are given little input into the management and strategy decisions that drive the organization.
But in the final analysis, the key question is: Are physicians at the decision-making table — and frequently enough and with a strong enough voice to play a role in shaping strategy and tactics?
Q: You also argue that part of the reason organizations lack effective physician leaders is because medical training doesn't address the business side of healthcare. And, you further argue, that many of the "physician leader development" programs hospitals proudly tout rely too heavily on classroom training. Why is this problematic?
CD: While there is certainly some merit in learning leadership through master's degree programs, educational sessions sponsored by organizations and programs that may be sponsored by associations, these approaches do have some limitations and drawbacks.
- Most extensive programs are quite expensive (some master’s degree programs cost in the $75,000 - $100,000 range).
- Most of these programs are episodic and may not be immediately applicable.
- These programs often take a long time to complete. Master's degree programs and similar programs usually require a full two years to complete.
- Many courses fail to have direct links to issues and challenges that are currently being faced in the physician executive’s home organization.
- The courses do not tie directly to the actual objectives of the job of the physician leader.
- The courses do not have experiential learning.
- The courses contain abstract and theoretical concepts and do not apply to day-to-day work.
- Perhaps most importantly, the fact is that learning by doing is the best way to learn management and leadership. Moreover, that learning should be akin to what is called crucible experiences (essentially experiences that take place when leaders are put into situations they have not confronted before, some risk is involved with the decisions made, and there is some personal pressure on the leader making the decision). When leaders are asked how they personally developed, they will indicate that learning by doing were critical parts of their growth.
Leadership development works best when (a) the educational material has direct ties to the actual job itself; (b) developmental is experiential — practice enhances what is learned; (c) development takes place in real world stresses and pressures – there needs to be some risk/reward involved; and (d) ideally there is a guide or coach to work with the physician and provide feedback and counsel. The best leadership development programs are highly customized and take place "on the field of battle." In book, "The Leadership Machine" (2002), Michael Lombardo and Robert Eichinger write that leadership "skill development is reported as 75 percent to 90 percent learned on the job."
Q: A significant portion of your book is dedicated to tips for identifying and selecting physician leaders? What are some of the most important ideas administrators should keep in mind with regard to this?
CD: Stated simply, it is critical to approach these tasks with a methodical and very well-thought out plan. There should be a systematic process, caution must be exercised to avoid simply choosing the best clinical leaders to move forward into leadership, and selection through the process of a popular vote of the medical staff is wrong for paid administrative positions.
Q: How or why is developing physician leaders critical to an organization's success in a value-based world?
CD: It is a gross over-simplification to attribute it to one word but quite frankly, the cost of healthcare has certainly played a significant role in getting us to where we are today. It is a common fact that the physician's order creates every activity involved in healthcare. This drives costs. At this point, healthcare costs are growing at an unsustainable rate and are a major source of future unfunded liabilities in the U.S. In addition, the cost shifting that has been done inside healthcare for the past fifty years will soon end, and reimbursement will place a greater emphasis on performance and risk bearing by providers. All of these changes must occur through the redirection of physicians.
But there are many other reasons that, when added with the cost issue, create a clarion call for increased physician leadership. Health reform, significant changes in the health care delivery system, a greater emphasis on quality and patient safety, and the move toward paying for value not volume have contributed greatly to this movement. Interestingly, more contemporary approaches to the practice of medicine have younger physicians working more in teams which requires leadership skills.
Clinical integration is perhaps the best overall umbrella moniker for all of the above. The movement toward clinical integration requires more physician leaders and those who are better prepared to lead and manage. Organizations who expect to be at the forefront will have physicians at the strategy and decision-making table.
To read an excerpt of the book, "Clinical Integration Readiness: 40 Questions," click here.