An evolving medical leadership position. Tomorrow's Vice President for Medical Affairs

The role of medical leadership in hospitals and health systems is under constant scrutiny and change. The nature of the Vice President for Medical Affairs (VPMA) position and its relationship to leadership in the health care system is explored through a national panel survey conducted recently. The effective VPMA will: be an aggressive manager able to implement change, address strategic planning and quality of care issues; have a high level of integrity; and be a good communicator and problem solver. The results of the research are presented in three sections. The first section describes the background characteristics and compensation of the VPMAs who participated in the survey. The second section focuses on the current role of the VPMA, including duties and responsibilities, job performance barriers and required skills. The final section addresses respondents' perceptions regarding areas for improvement in the role of the VPMA, as well as projections for future changes in this position.     

Developing loyal physicians: a five-point plan

Now, more than ever, health care centers are forced to compete for physicians. There could be no greater argument in favor of establishing the position of Vice President for Medical Services. A physician executive is infinitely more qualified and better prepared to understand the probable reaction of different types of physicians when "loyalty" to the organization is the central issue. The Vice President for Medical Services seems best positioned to remind the Chief Executive Officer and the Board to keep sight of the legal, and moral, duty to "exercise reasonable care in the selection of a medical staff and in granting specialized privileges," including selecting practitioners who are "worthy in character and matters of professional ethics."     

Sammons departure portends organizational changes

The American Medical Association enters the '90s at a peak of its power and influence. Its recovery from the institutional doldrums of the mid-1970s is now complete. The surprise resignation of Executive Vice President James Sammons, MD, following the Interim Meeting of the AMA House of Delegates could position the AMA for further changes and for an increasingly influential voice in health care policy making. The College Delegate and Alternate Delegate to the AMA House report on the December 1989 meeting.     

Selecting a physician executive.

Selecting a physician executive can be a complex task. The process is complicated by the explosive demand for qualified physician executives. Although the number of physician managers has grown since 1979, the demand still outstrips the supply of physicians with track records. Also, many organizations have never had a full-time person serving in the capacity of Medical Director or Vice President of Medical Affairs, so the process of recruiting this person is new to them.     

Premium will continue to be on performance. Interview by Wesley Curry.

With a new name for its professional organization (the American College of Physician Executives) and a new certifying organization (the American Board of Medical Management), the profession of medical management is in the throes of significant and far-reaching change. At the College's National Conference in Washington, D.C. in May, we talked to two leaders of the profession, Michael B. Guthrie, MD, MBA, FACPE, and Robert H. Hodge, Jr., MD, FACPE about what the future holds for physician executives and what physician executives can do to position themselves for success. Dr. Guthrie, the Immediate Past President of the College is Vice President for Business Development, Penrose/St. Francis Healthcare System, Colorado Springs, Colo. Dr. Hodge, the new President of the College, is a Program Director, W.K. Kellogg Foundation, Battle Creek, Mich.     

Status quo won't work

The division between those who provide health care services and those who pay for them may be widening. Costs continue to rise, quality remains ill-defined, and there don't seem to be any easy answers to the dilemma. Joseph W. Duva, Director of the New York Region Health/Welfare Benefits Consulting Practice of Ernst and Young, believes the answer has been found. While Director of Employee Benefits at Allied Signal Corp., he was instrumental in the formulation of a total managed health care plan for employees. He recently founded the Managed Health Care Association to share the experience at Allied Signal with others and to provide a business forum for exploration of the managed care concept. Duva's views on managed care as a cost containment strategy were the subject of an interview conducted by Physician Executive at the National Conference of Physician Executives in San Antonio in May.     

Physician leadership. The time is now

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.     

Innovative leadership: generating ideas.

One of the most challenging functions a physician executive performs is being an innovator--coming up with new ideas to keep ahead of the pack and to solve problems that need fresh solutions. Robert Hodge, MD, CPE, FACPE, and Barbara Linney interviewed Roger Schenke, Executive Vice President of the American College of Physician Executives, and gleaned seven pointers that you might consider to help generate a flow of new ideas or when you get "stuck." They are: (1) read voraciously and link unlike things together; (2) talk to people whose circle is bigger than yours; (3) stop thinking about the problem and focus on something else; (4) care enough to keep wrestling with a problem and not give up; (5) stay open to new ideas even if they are uncomfortable; (6) be willing to risk and take chances; and (7) find a place to carry out the ideas.     

Culture in chaos: the need for leadership and followership in medicine.

The health care industry is changing at a dizzying pace and most of its players are struggling to maintain some form of the status quo. But resisting change will not prove fruitful--ultimately, it will rob physician executives of the opportunity to be architects in designing a new, more efficient health care system and their role in it. Because health care is a complex adaptive system (CAS)--change occurs rapidly and events are unpredictable--the old command and control style of leadership and a linear way of interpreting events is too rigid and, therefore, an ineffective model for guiding change. Complexity science offers insights about leading for change. In CASs, changes emerge in response to environmental demands for adaptability. Since the nature of these demands is unpredictable, the role of leadership is to manage the relationships and context out of which these changes emerge. A leadership style is called for that leads to purpose, makes positive changes by influencing context and relationships, and takes followers to a better place.     

Physician leadership. Learning to be a leader

As the business role of health care delivery expands and complex reform is imposed, physicians must assume leadership roles and imprint medical expertise on business dynamics. Before the end of this century, health care and its delivery will likely become unrecognizable to those who ended their practices only a decade ago. Traditional management will wither away to be replaced by self-managed, self-trained, and self-motivated workers, no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all.     

Compensation for elected hospital medical staff leadership

As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership.     

Serving the public by serving the profession. Interview by Wes Curry.

With the formation this year of the American Board of Medical Management, the American College of Physician Executives took a giant step toward formal recognition of the medical management profession as a specialty of medicine. Much needs to be done, however, to make that dream a reality. Late last year, Physician Executive talked with Donald G. Langsley, MD, Executive Vice President of the American Board of Medical Specialties (ABMS), about the certification process for specialties of medicine and about the role of ABMS in ensuring high standards for the medical profession and for the practice of medicine.     

The Role of Clinical and Process Quality in Achieving Patient Satisfaction in Hospitals

Managers constantly struggle with where to allocate their resources and efforts in managing the complex service delivery system called a hospital. In the broadest sense, their decisions and actions focus on two important aspects of health care—clinical or technical medical care that emphasizes “what” the patient receives and process performance that emphasizes “how” health care services are delivered to patients. Here, we investigate the role of leadership, clinical quality, and process quality on patient satisfaction. A causal model is hypothesized and evaluated using structural equation modeling for a sample of 202 U.S. hospitals. Statistical results support the idea that leadership is a good exogenous construct and that clinical and process quality are good intermediate outcomes in determining patient satisfaction. Statistical results also suggest that hospital leadership has more influence on process quality than on clinical quality, which is predominantly the doctors' domain. Other results are discussed, such as that hospital managers must be mindful of the fact that process quality is at least as important as clinical quality in predicting patient satisfaction. The article concludes by proposing areas for future research.     

The evolution of the hospital medical director: a historical perspective.

Numerous articles have been written regarding the concept of the Medical Director, especially in the community hospital. Extensive research of the topic yielded little information in a readily available form as to the substantive, historical sequence that led us to the present concept. The material herein represents an overview of my perspective on how we got here and is presented as a based upon which further review may be undertaken by those interested in such endeavors.     

Effects of role variables on job satisfaction

This study examines the effects of role variables on job satisfaction among physician and non-physician executives in hospital settings. Positive relationships were found for both groups between role variables and job satisfaction. The results indicate that role variables have a significant effect on stress, job satisfaction, and organizational commitment in the physician executive and the non-physician health care executive. On a theoretical level, this research allowed for an extended test of role theory, specifically as it applies to the management of health care. The implications of these findings for role theory and the physician executive are discussed. Since this study is of an exploratory nature, it offers new insights into the field of health care management, and the physician's role as the executive.     

The new rules of leadership and organizational politics

As the health care industry continues to experience unprecedented change, organizational politics are also evolving. Major changes are underway in the rules of engagement and how management and workers behave on the job. The new rules of the game include: Practice leadership, not management; practice inclusion with a vengeance; practice modesty and consideration and demand both; act on rumor, don't await confirmation; aggressively collect allies; understand the politics of voice mail; and know that position power isn't personal power.     

Management education for medical students.

There is little doubt that the economics, management, and delivery of health care in the United States are currently in an unprecedented state of flux. Prospective payment, cost containment, and corporatization of health care delivery are rapidly replacing retrospective fee-for-service reimbursement and unmanaged provider practice patterns. Though ultimately certain to affect significantly physicians now in training, these changes have been afforded little attention in the undergraduate medical curriculum. At Hahnemann University, this is no longer the case. "Management Education for Medical Students" is an elective, intensive, eight-week experience for senior medical students. Following a thorough orientation to the workings of organizations through which health care is delivered, medical students receive both didactic and project-oriented instruction in university hospital administration during the first four weeks. During the course's second half, students are offered specialized training in the part of medical management that links the clinical and the financial aspects of health care management.     

Managing health care quality.

Using the cited principles of professional staff credentialing and quality assurance, a department chairman, medical director, or other health care executive will be in an excellent position to assess quality of care against established standards and manage problems in the routine provision of medically appropriate care. He or she will also be able to assure the hospital's board that the hospital and its medical staff are well positioned to meet future challenges to provide effective quality, utilization, and risk management.     

Work satisfaction, health, and stress: A study of Dutch nurses

A study was conducted to compare nurses' work satisfaction and feelings of health and stress in five different nursing departments: a cardiac care unit and a general surgical ward in a general hospital; and an admissions department, a short-stay department, and a long-stay department in a psychiatric hospital. One hundred nurses took part in the study: the instruments used were questionnaires and structured interviews. The main results showed that:

(1) nurses in the cardiac care unit had the most positive satisfaction scores

(2) nurses in the general surgical ward had the most positive scores on the health and stress variables

(3) feelings of dissatisfaction and stress were most prominent in the short-stay department and, to a lesser extent, in the long-stay department.

The findings are interpreted in terms of the different work situations and die implications for hospital management are discussed.

Dr J. A. Landeweerd graduated in industrial and organizational psychology in 1968 (PhD in 1978). He has worked at Eindhoven University of Technology (Department of Industrial Engineering) and now holds a position as senior lecturer at Limburg University (Department of Health Sciences), where he is project-leader for a number of research projects on the relationships between work and health.

Nicolle Boumans, MA, graduated in health sciences in 1985 (specialization: nursing science) and is now a research assistant. She is working on a PhD thesis concerned with the relationship between task characteristics of nurses and their reaction in terms of job satisfaction, health and stress.     

Design requirements for health care production control systems

This paper addresses the issue of determining design requirements for production control in health care organizations, with a restriction to the internal production control of hospitals. Hospital management has limited possibilities to control hospital production, as hospital production processes are driven by medical specialists who, however, do not manage that process. We consider therefore the hospital as a virtual organization, consisting of a number of relatively independent businesses in a common framework. Each business unit functions as a focused factory for a range of more or less homogeneous products. Production control principles can be applied to each of these businesses, but not to the system as a whole. A number of elements from classical production control theory can be also applied to health care, i.e. the use of decoupling points, the bottleneck-oriented approach, and the operational control between production and market. However, important factors that need to be considered in health production control are that often specifications on quality are not available at the start of the process, and that there is strong interaction between the patient and the process. Our conclusion is that a dedicated framework for approaching hospital production control is necessary. The specific characteristics of hospital care and its state of production control development are the main arguments for this dedicated framework.