Examining Pathways from Innovation Orientation to Patient Satisfaction: A Relational View of Healthcare Delivery*

The federal government and industry leaders view innovation as a potentially fruitful way to improve hospital performance, specifically patient satisfaction. However, translating a hospital's innovation orientation into improved performance is challenging given that important network participants—namely physicians—may possess different aims. Grounded in Relational RBV, this study tests a model linking innovation orientation to patient satisfaction through a pathway of knowledge‐sharing routines (physician partnering and customer relationship management) and complementary capabilities (hospital responsiveness). Further, this study investigates the moderating role of physician employment (a form of governance) by examining hospitals with high and low levels of employed physicians. Structural Equation Modeling results from a paired sample of primary survey and secondary data from 173 acute care hospitals in the USA reveal the following. Hospitals with high levels of employed physicians translate innovation orientation into patient satisfaction by using customer relationship management (CRM) programs to influence hospital responsiveness directly, ultimately leading to patient satisfaction. Hospitals with low levels of physician employment use CRM programs in a fully mediated fashion to inform physician partnering activities, which influence hospital responsiveness, driving patient satisfaction.     

Physician executive contracts: negotiating the future

Once viewed as a matter of standard protocol, physician executive contracts have become as complex as the health care industry itself. Historically, hospital administration and physicians negotiated a few key points, then sent the ideas to an attorney for insertion of standard legalize and boilerplate. Today, physician executive contracts are an important part of the changes in health care. They not only cover traditional hospital and physician relations, but increasingly apply to new types of relations (such as employment) between hospitals and physicians, physicians and physicians, and health plans and physicians. In this article, we will explore both the "content" and the "context" of physician executive contracts. Content will deal with the specific provisions typically included in contracts. Context will address issues associated with preparing for and negotiating a contract.     

Serf or citizen: physician status and organizational structure

For more than a decade, dynamic changes in the health care industry have created new organizations for physicians. The major change for physicians has not been the organization itself, but the principles by which it is governed. This fundamental shift is studied with its impact on physicians, by analogy, becoming more like serfs or more like citizens. A review of the general organizational direction and results of non-physician health care organizations is made followed by the statistical trends of physician groups. Historical comparisons of non-health care industries are made with current organizational choices of physicians and physician groups. Observations of physician decisions are made identifying the direction they send physician status along the continuum from serf to citizen. Physicians are unknowingly making decisions regarding the principles by which they will be governed in new organizations. The choices they are making give them less autonomy and less opportunity to make future choices. The seductive invitation to spend less time in administrative matters and more time practicing medicine is a siren's call that will diminish the status of physicians and the autonomy by which medicine is practiced.     

Linking Electronic Medical Records Use to Physicians’ Performance: A Contextual Analysis

Electronic Medical Records (EMR) studies have broadly tested EMR use and outcomes, producing mixed and inconclusive results. This study carefully considers the healthcare delivery context and examines relevant mediating variables. We consider key characteristics of: (i) interdependence in healthcare delivery processes, (ii) physician autonomy, and (iii) the trend of hospital employment of physicians, and draw on theoretical perspectives in coordination, shared values, and agency to explain how the use of EMR can improve physicians’ performance. In order to examine the effects of physician employment on work practices in the hospital, we collected 583 data points from 302 hospitals in 47 states in the USA to test two models: one for employed and another for nonemployed physicians. Results show that information sharing and shared values among healthcare delivery professionals fully mediate the relationship between EMR use and physicians’ performance. Next, physician employment determines which mediating variable constitutes the pathway from EMR use to physicians’ performance. Finally, we highlight the impact of shared values between the hospital and physicians in enhancing information sharing and physicians’ performance, extending studies of these behaviors among network partners in industrial settings. Overall, our study shows that EMR use should be complemented by processual (information sharing), social (shared values), and structural (physician employment) mechanisms to yield positive effects on physicians’ performance.     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

The new physician role as employee.

Rapid and ongoing changes in the way in which medicine is practiced and health care services delivered have made employees of physicians who were once the very definition of entrepreneurs. If this new role is difficult for physicians, it is doubly difficult for those who must manage such employees. To be effective managers of other physicians, physician executives must be aware of the historical and sociological basis of the physician profession.     

Lonely at the top and loving it: physicians as CEOs

As little as five years ago, most hospital board members scoffed at the idea of hiring physicians as chief executive officers or chief operating officers. Physicians, they maintained, belonged at the bedside, not in the board room. For the most part, physicians didn't take issue with this thinking. Profit and loss statements, strategic planning, and other CEO duties were alien. Besides, being a "suit" was unconscionable, a total fall from the true grace of medicine: patient care. Dramatic changes in health care have wrought dramatic changes in the mindsets of both board members and physicians. Today, both sides have developed a new perspective on physicians in top hospital administrative positions. In this article, the author reports on the experiences of physician executives who have made the trip to the top.     

Be positive--it's a necessary strategy.

The hallmarks of successful health care organizations include: A positive physician culture; meaningful physician involvement in governance and top management; and stability and strong community roots. Success is most likely where physicians in the facilities are having professional fun, where freedom from negativity allows them to perform at their highest level of quality. When a positive physician culture takes hold, remarkable things can occur. In the best scenarios, physicians are deeply involved in strategic direction, as well as in practice. They are part of making the decisions, instead of merely grumbling about decisions made by others. The column provides suggestions for creating a positive physician culture.     

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.     

The managed care world order. The revolution is here

What are the belief clashes caused by the shift from a fee-for-service medical setting to a managed care environment? Right now, most physicians are enculturated in the old world order that emphasizes physician autonomy, control, security, and specialness. Physicians feel squeezed--by third-party payers wanting to be involved in the decision-making process of care delivery and by a new focus on teams versus the captain of the ship role. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. If physicians have clear and realistic expectations, they can better cope with the uncertainties they face. And, the only realistic expectation in the medical profession is increasing uncertainty. Here are 10 predictions of what is happening in the health care industry--a list of the belief clashes that are so unsettling to those practicing medicine.     

The changing academic health center. The death of the traditional academic physician

Organizational change is required if academic health centers (AHCs) are to survive the decreased societal commitment to them. The changes will generate significant emotional responses in the physicians employed by such institutions. This article presents an analogy between the reactions of academic physicians to the changes they are experiencing, and the stages of grief that Dr. Kübler Ross described in terminally ill patients. By placing physician responses in this context, emotional responses to organizational changes can be more easily understood and managed, allowing academic physicians to devote more energy to facing the threats to AHCs in an innovative and constructive manner.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.     

Making a match: inexperienced physician executives and the job market

Hospitals and other health care organizations are adding physician executives at such a rate that demand is outstripping supply-there are more opportunities for seasoned physician executives than there are physicians with track records as medical managers. It is possible that hiring management will have to consider the employment of a physician who wants to be in management but has no track record as a physician executive. In some cases, it may even be preferable to employ a neophyte physician executive, especially when the physician is a respected clinician already on the organization's medical staff. In selecting such a physician, however, an evaluation must be made of the probability that the physician will be successful in the new role. The author points to 10 criteria that the hiring organization should observe in hiring inexperienced managers.     

Increasing physician engagement. Using norms of physician culture to improve relationships with medical staff

Comments on the 2004 survey identified that physicians thought it was too early to judge whether the new structure itself was successful. This year, the survey will be repeated to measure the effectiveness of the new structure and to help administrators set goals to further improve physician engagement levels. Meanwhile, Mercy & Unity is using the tenets of the physician compact, elements of physician culture, and elements of administrative culture to inform new process-improvement activities. More study is needed to identify whether Mercy & Unity's techniques of reorganization contributed to the higher rates of physician satisfaction and engagement, but it is our belief that incorporating physician cultural norms into the process helped prevent the change process from turning the horse into the proverbial camel.     

The new breed

Structural changes within the health system--particularly in the organization and financing of services--have made new and different opportunities available to physicians interested in management. What types of physicians are currently going into management? How do they compare to others who have been in management for a longer period of time and to the "traditional" portrait of the physician executive? The author profiles the emerging, contemporary physician executive and explores the implications for the viability of the field of medical management as a whole.     

Zu den Auswirkungen von Arbeitszeitmodellen im ärztlichen Dienst von Krankenhäusern

In 2004 a new working time law for physicians in hospitals was introduced, which has up until now been rarely researched in theory and is implemented in practice partially in form of new working time models, partially by relying on allowed variation rules within the law. Meanwhile, there are new discussions about changes of working time directives on the European level. This article aims to analyze the desired effects of the new working time law to decrease the workload, improve the possibilities of patient care and increase the working time satisfaction of physicians. To this end, a primary data collection is conducted in 15 hospitals and 35 hospital departments, generating 261 questionnaires, in order to empirically assess the theoretical model with the constructs working time model, workload, working time satisfaction, and possibilities of patient care using regression analyses. It can be shown that the new working time models decrease workload and enhance working time satisfaction of hospital physicians, but have no significant influence on the possibilities of patient care. These results are consistent for different ownerships and sizes of hospitals as well as for most services. No significant differences in the answers between various physician groups exist either.     

Why some managers fail.

Among modern societies, the American culture is one of the most competitive. And within that culture, physicians are among the most success-oriented professionals. This is easy to understand, in that, for our patients, success is equated with well-being and continuance of life. This emphasis upon success is also finely honed in the physician executive. Commonly, our institutional goals revolve around providing a high-quality health care product in a cost-effective manner. For the physician executive, success is based largely upon the extent to which institutional goals have been attained or, in the present environment, if it has survived. But the actual ingredients for the physician executive's success will depend upon a variety of diverse factors, both personal and environmental.     

Is there a physician union in your future?

Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?"     

Cutting out the middlemen: physicians as providers, direct contractors, and payers. Interview by Donna Vavala

While many physicians and physician groups are forging alliances with other groups, with hospitals, and with other elements of the health care delivery system, an Ohio group decided that the loss of autonomy involved in these approaches was not acceptable. Instead, the group became the core of a new entity aimed at restoring physician control over the provision of and payment for health care services. In an interview with the principal of the new organization, Physician Executive learned the basis for the venture.     

Leadership is the key to chief medical officer success

Senior physician executives were surveyed in 1998/99 to ascertain that they see as their greatest value to their organizations. They believe that their most significant contribution is their accumulated knowledge and experience--both in medicine and management. This medical management perspective is considered the key advantage of serving on the senior management team and helping to shape the organization's decisions and direction. Additionally, they rated their relationships with physicians as a critical aspect of their position. They were also asked what activities they most enjoyed. The number one response was working with the physicians on the medical staff and in the community. This includes the day-to-day involvement as a leader, as a mentor and educator, and overall as a liasion to the organization's practitioners. The activities that they found most rewarding were also those they perceived to be of greatest value. If these physicians are correct about what is valued in their organizations, they are the right people in the right jobs--and they enjoy what they do.