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."     

An approach to the impaired physician

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.     

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.     

Formatting and presenting quality data to medical staffs and hospital boards

A host of historical and practical precedents have made hospitals responsible for the quality of care rendered within their facilities. The medical staff and the board of trustees share in this responsibility. Increasing demands for demonstrative evidence of the quality of care in an institution have made the process data-based. There is no substitute for specific data on the performance of both the hospital and its providers in the delivery of care. The trick, however, is in presenting this information to the medical staff and the board in a fashion that will be understandable and that will still maintain confidentiality of provider and patient. The authors offer a presentation system that has met with success in their community hospital.     

Sometimes we're our own worst enemies

There is a sense of frustration among physicians involved in the decision and policy making processes within health care institutions. Because the endpoint is reached at glacial speed, too much time, money, and opportunity is lost. The decision making process can be repetitious and tedious because of unnecessary steps. By eliminating certain tactics and strategies employed by upper-level management in many health care institutions, the decision making process becomes more effective. This article focuses on the medical staff's role in the decision making process; explains why tactics to involve the medical staff are ineffective and why eliminating the medical staff from certain aspects of the process does not jeopardize the institution; and concludes that the hospital board and its delegates should be autonomous in the decision making process.     

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.     

Medical staff handling of concerns with physicians' performance

Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article.     

Reinventing a medical specialty. Using anesthesiology as a model for change

In only a decade, anesthesiology has reversed its fortunes from an underrepresented specialty in the 1980 Graduate Medical Education National Advisory Committee report to "a specialty in trouble" featured in The Wall Street Journal. This article focuses on anesthesiology and its work force dilemma as an evolving specialist model for change. What is happening to anesthesiology will not be unique--managed care competition will affect all physicians. Most specialties will have to reshape curricula and redesign education programs and academic delivery systems concentrating on fewer trainees. What are the options for coping with physicians grieving over lost dreams, such as autonomy and solo practice, while redesigning a medical specialty? The authors untangle fact from fear, mission from myth, and offer strategic thinking and solutions.     

Due process key element of physician grievance.

The concept of grievance procedures, when applied to physicians, has a foreign ring to it. We ordinarily associate grievance procedures with unions and labor relations activities unrelated to professional conduct and behavior. As described in the preceding article, grievance procedures usually are extremely limited, having been created to resolve very specific violations of collective bargaining agreements in a unionized company or of conflict resolution policies in a nonunion environment. In health care organizations, "due process provisions" are designed to resolve specific conflicts in the relationship between the medical staff and individual medical practitioners.     

Re-forming the traditional organization medical staff

The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play.     

Health care applications of complexity science. Life at the edge of chaos

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.     

In pursuit of physician/organization linkage

A friend of mine once said that medical staff/administrative relationships are the Bermuda Triangle of health care management. The Bermuda Triangle, as I recall it, is an area of the Atlantic Ocean into which ships and planes disappear without a trace, for no apparent reason. Sometimes, especially late at night on reruns of "Twilight Zone," these planes reappear years later, crew intact and youthful. Sometimes, salt and sharks get the ships, planes, and voyagers. In a like manner, problems in medical staff/administrative relations draw consultants into a vortex. Sometimes, the consultants and their reports float to the surface a long afterward. Sometimes, they are digested by the organization and become a part of its mythology. Sometimes, they vanish forever. This is the story of three consultations. All were intended to make recommendations concerning the structural relationship of management to the physicians and their groups in our HMO: How to link the physician organization to the corporate structure. Like any narrative, this story is constructed to provide a context for reflection and is not intended to question the value of the contribution of specific individuals or companies.     

Hospital medical directors, quality of care, and financial returns

You are a physician executive working very hard within a hospital on all sorts of medical staff issues and quality of care. You answer to the board. The latter, through its administrators, may still have difficulty documenting the precise value of a full-time physician executive. Your hospital is losing money or not making enough profit for capital expenditures and salary raises. It is considering or will have to consider staff cuts. What can you do that will influence the bottom line, produce a quality image, and quantify your value?     

Transfer of ownership: antidote to closure

In the 1990s, many hospitals will continue to be confronted with financial, regulatory, and medical staff issues that threaten their survival. Inadequate reimbursement, HCFA certification problems, and aging medical staffs are just a few examples of the many difficult issues health care institutions face today and that have contributed to the phenomenal number of failing hospitals. Failing hospitals must consider all their options, such as turnaround process, modification of service mix, change to a specialty hospital, transfer to a new owner, or closure. Selection of the most appropriate option hinges on the hospital's goals and mission, its need in the community, and its owner's and sponsor's desire or ability to continue in the health care business. This article will discuss the transfer of ownership option.     

Certain physician recruitment and retention activities found to be suspect

A new "Fraud Alert" from the Office of Inspector General of the Department of Health and Human Services will cause hospitals to be especially circumspect in their dealings with actual and potential members of the medical staff. The authors analyze the alert and its potential impact on hospitals and physicians.     

A strategy to enhance accountability in health care delivery

The New York State Department of Health surprised many in the hospital industry and medical community when, in June 1987, it proposed as regulation that the governing body of each acute care hospital appoint a medical director who would be assigned responsibility for the direction of the organized medical staff. Such a proposal, without modification, has been incorporated in the New York State Hospital Code--Minimum Standards, effective January 1, 1989. While a strong case can be made for this position in hospitals, its value has long been recognized by a wide variety of organizations.     

Management competencies required in ambulatory care settings

A study was conducted to identify the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years. The specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies were also explored. The Delphi techniques were used to analyze responses from two surveys from members of the American College of Medical Practice Executives. The most important competencies were grouped into 13 management domains, each with specific SKAs. "Managing health care resources to create quality and value" and "fundamentals of business and finance" were rated as the most important competencies. The most frequently rated SKA was the "ability to build and maintain credibility and trust."     

Improving performance in a contracted physician network

Health care organizations face significant performance challenges. Achieving desired results requires the highest level of partnership with independent physicians. Tufts Health Plan invited medical directors of its affiliated groups to participate in a leadership development process to improve clinical, service, and business performance. The design included performance review, gap analysis, priority setting, improvement work plans, and defining the optimum practice culture. Medical directors practiced core leadership capabilities, including building a shared context, getting physician buy-in, and managing outliers. The peer learning environment has been sustained in redesigned medical directors' meetings. There has been significant performance improvement in several practices and enhanced relations between the health plan and medical directors.     

The future of medical practice

Managed care of some kind will dominate the future of health care, but the unresolved crucial question concerns ownership of the managed care plans. An investor-owned managed care industry now holds sway, but I do not expect it to last very long. In the long run, physicians must be in charge of medical care, but they must live within budgets and be accountable to payers and to their patients. The only solution that makes sense to me is one based on multiple local physician networks, organized on a not-for-profit basis. I predict that staff and group-model HMOs will be the mainstay of the medical care delivery system within a few decades.     

The medical practice as business organization

Medical practices historically have not been examined in terms of their organizational structures and of the appropriateness of their structures for survival as business entities. In this paper, we propose a model for the typical medical practice and discuss its fit with current organizational theory. It is apparent that the medical practice organization does not fit with the demands of a rapidly changing and complex environment. To survive and grow, the medical practice organization must align itself with others that have an interest and stake in the health care system, develop teamwork among physicians, bridge the gap between physicians and others in the organization, and recognize that the work done in the organization depends on other components of the organization.