Trends in managed care organizations: implications for the physician executive.

The rapid change in the managed health care industry is placing substantial demands on the managerial and leadership skills of physician executives. These changes are forcing a reevaluation of the fundamental principles of managed care organizations, specifically in terms of patient satisfaction, cost containment, and quality health care. Additionally, the physician executive will be confronted with substantial issues concerning future staffing needs. This article assesses the health care industry's environment to suggest where managed care is going and how physician executives should position themselves to optimize their position in the marketplace.     

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.     

What skills do physician leaders need now and in the future?

The role of the physician leader is moving beyond traditional medical staff issues. A recent national survey of physician leaders shows a growing need for education on specific technical, leadership, and practical skills. The results reveal the medical leadership skills that physician executives consider important today, and provide a window to the future about the skills that will be important tomorrow. Physicians say they need training now in quality assurance, clinical benchmarking, decision-making, and strategic planning. And when they gaze into the future and see the rapid changes throughout health care, they say they'll need more training in communication, organizational change, effective listening, and systems thinking.     

Can doctors and administrators work together?

The working relationship between physicians and health care organizations has dramatically changed since the introduction of competitive factors. Fifer suggests that future doctors may have as many as five or six economic relationships with their associated health care system, in contrast to the singular role as admitting physician of the past. The physician will continue to admit patients, but may also belong to an HMO or some other joint venture (freestanding ambulatory care center, outpatient laboratory, etc.), be salaried part time for leadership roles, be a leader in some other parallel economic venture, etc. Physicians are already assuming multiple roles as health care providers, private entrepreneurs, and joint venture partners with hospitals. Hospitals and health care systems also continue to change through vertical and horizontal integration. Traditional clinical departments are becoming blended into product line entities, and a sophisticated executive team of market-oriented specialists now augments the traditional administrative leadership. So, from a tradition of predictable roles, relationships, and authority structures, we are now attempting to thrive and prosper with many new partners in an integrated, complex, and conflict-ridden set of interrelationships.     

U.S. hospitals mired in bureaucracy: 10 roadblocks to change

Given the dot.com revolution in health care, advancing medical technology, and dissatisfaction with managed care, fundamental change is the order of the day in U.S. hospitals. Some hospital leaders are responding effectively to these new century challenges. But too many only tinker with existing systems, hoping to get by with choices that are comfortable, conventional, and convenient. Meanwhile, the sharks of dwindling public confidence and lost political support circle ever closer. The vice president of medical affairs (VPMA) is positioned at the vertex of disparate organizational, interpersonal, and external forces and can lead the way in recognizing and removing common roadblocks delaying needed change. External obstacles include: (1) Too much regulation; (2) too many attorneys; and (3) theatrical local TV newscasts. Internal factors include: (4) A natural fear of change; (5) arguing when we do not really disagree; (6) Cake Committee management mentality; (7) over-aggressive downsizing; (8) natural conflict in choosing a health care ethic; (9) the past; and (10) lack of trust. Hospital leaders need to effectively act, not just think, "outside the box."     

Physician leadership. How do physician executives view themselves?

Most physician executives today have acquired substantial management training and experience, and many have worked with and relied on the expertise of mentors for their career guidance and development. Physician executives are actually becoming executives who happen to be physicians. They view themselves first as leaders, then as physicians, and finally as managers. That is a remarkable transformation in perception. To chronicle this process, Witt/Kieffer, Ford, Hadelman & Lloyd conducted a national survey this spring among senior physician executives in both payer and provider organizations. The data provide a "snapshot" of their role, and may also suggest some future scenarios for the industry. The primary reasons for choosing to pursue a management role noted by most participants include a desire to be part of the health care solution and an interest in management and leadership challenges.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

Who will lead?

A recent survey conducted by the UCLA Center for Health Services Management and the Physician Executive Practice of Heidrick & Struggles, an executive search firm, sheds light on the emerging physician executive's role. The goal of the research was to identify success factors as a means of evaluating and developing effective industry leaders. Respondents were asked to look at specific skills in relation to nine categories: Communication, leadership, interpersonal skills, self-motivation/management, organizational knowledge, organizational strategy, administrative skills, and thinking. Communication, leadership, and self-motivation/management emerged, in that order, as the three most important success factors for physician executives. An individual's general competencies, work styles, and ability to lead others through organizational restructuring defines his or her appropriateness for managerial positions in the health care industry.     

Clinical reengineering. Integrating medical and operational management

In the continuing push for cost containment in health care, many organizations have turned to cost reduction methods that fundamentally change the way care is delivered. As health care organizations continue to make financially-driven staffing changes that impact patient care, medical leadership must take on greater responsibility for operational management. Physician executives are uniquely qualified to take on leadership roles in work redesign, and must do so to ensure excellent and fiscally-responsible patient care. This article presents a proven methodology for work redesign that helps physician executives apply their clinical skills to operational management in designing new health care delivery models.     

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.     

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 VPMA (vice-president, medical affairs)

In the past, the VPMA's role was clearly defined. So were the skills required to do the job. Initially VPMAs served an inside role in an organization as the liaison with the medical staff and the hospital administration. That role has matured and is currently evolving. Ultimately the expansion of the VPMA role will provide alternative career directions for physician executives. The wise physician executive learns from those who have knowledge--or who are in the process of acquiring it. That means keeping an eye on active managed care markets nationwide for trends that may be coming to his or her locale. The physician who does not do this kind of professional introspection and evaluation of the national market may find him- or herself professionally behind the curve.     

Leadership clarity and team innovation in health care

The relationships among leadership clarity (i.e., team members' consensual perceptions of clarity of and no conflict over leadership of their teams), team processes, and innovation were examined in health care contexts. The sample comprised 3447 respondents from 98 primary health care teams (PHCTs), 113 community mental health teams (CMHTs), and 72 breast cancer care teams (BCTs). The results revealed that leadership clarity is associated with clear team objectives, high levels of participation, commitment to excellence, and support for innovation. Team processes consistently predicted team innovation across all three samples. Team leadership predicted innovation in the latter two samples, and there was some evidence that team processes partly mediated this relationship. The results imply the need for theory that incorporates clarity and not just style of leadership. For health care teams in particular, and teams in general, the results suggest a need to ensure leadership is clear in teams when innovation is a desirable team performance outcome.     

Congratulations ... you're fired!

Being fired as a physician executive is the dark side of burgeoning opportunities for health care leadership. The risk of termination is 20 to 40 times higher than for clinicians. Several approaches to calculating and predicting the probability of being fired are presented, based on a recent survey of American College of Physician Executives members and the author's professional observations. The survey identified several factors that are associated with a higher risk of being fired. These include structural conditions like organizational type and position, as well as factors ranging from being the first person in a new or unclear job to working for an entity with two or more years of significant financial losses. Persistent conflict with a boss or board member--concerning personal style or organizational strategy--is another commonly present danger signal. Additional predictive variables include recent termination or departure of a boss, recent merger, and widespread organizational downsizing or re-engineering. This article suggests strategies to better predict high-risk situations, to prevent termination, and to increase the likelihood of your professional and personal well-being when termination becomes inevitable.     

Leading in a chaotic health care environment

How can physician executives be effective leaders during a time of such upheaval in health care? How does anyone lead in a confusing environment where planning seems impossible? Is effective leadership even possible when no one seems to understand what is going on? These important questions are addressed in this article. Health care is a confusing field. But it still needs effective leadership. Even though nobody really knows what is going on, physician leaders can play a beneficial role by encouraging everyone they work with to experiment and innovate with ways to make health care work better for patients. Physician executives can insist on accountability and on implementing what really works in their given context, rather than what the latest theory states should work.     

Organizational violence and aggression: Development of the three-factor Violence Climate Survey

The aim of this study is to examine the concept of health-specific leadership, differentiate it from sound general leadership and identify whether it has an impact on employee strain, alongside general sound leadership practices. Health-specific leadership is conceptualized as the leader's explicit consideration of and engagement in employee health. The study is based on research in the field of leadership impact on employee strain, health and well-being, extended by recent findings of the importance of domain-specific leadership constructs. As indicated by previous relevant studies, we include psychological climate for health, role ambiguity and job satisfaction as mediating variables. Using structural equation modelling, a sample of 1027 employees of the German tax administration was examined. The results show differential effects for health-specific and general sound leadership. While neither of these two aspects of leadership exhibited a direct association with employee strain, general sound leadership practices were significantly related to lower employee strain through lower levels of role ambiguity, better psychological climate for health and higher job satisfaction. Health-specific leadership was associated with higher levels of psychological climate for health, but also higher role ambiguity.     

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.     

Mission impossible? Effects of crisis,leader and follower strain on health-oriented leadership

Previous studies underline positive effects of health-oriented leadership for follower well-being. However, it is not clear whether and to what extent situational and personal factors influence health-oriented leadership behavior towards employees (i.e., staff care). We examine the effect of crises and the moderating role of strain for the relationship between strain and staff care in two studies. The first study investigated main and interactive effects of crisis and leader strain on staff care in a cross-sectional survey (N = 201). To test for causality, we complemented our findings with an experimental vignette study (N = 169) and extended our findings with regard to the influence of follower strain. As expected, results of both studies showed negative effects of crisis and leader strain on staff care. Furthermore, crisis effects on staff care were contingent on both leader strain (Study 1 and 2) and follower strain (Study 2): While leader strain strengthened the negative relationships between crisis and staff care, follower strain served as a buffer. These findings support the assumption that staff care is at risk in crises particularly when leaders are strained. However, it is a positive finding that staff care is still feasible on a moderate and relevant level and that leaders respond to follower strain with additional efforts regarding staff care even in crises. The study contributes to the clarification and better understanding of situational contingencies of leadership behavior.     

Born to lead? A twin design and genetic association study of leadership role occupancy

We address leadership emergence and the possibility that there is a partially innate predisposition to occupy a leadership role. Employing twin design methods on data from the National Longitudinal Study of Adolescent Health, we estimate the heritability of leadership role occupancy at 24%. Twin studies do not point to specific genes or neurological processes that might be involved. We therefore also conduct association analysis on the available genetic markers. The results show that leadership role occupancy is associated with rs4950, a single nucleotide polymorphism (SNP) residing on a neuronal acetylcholine receptor gene (CHRNB3). We replicate this family-based genetic association result on an independent sample in the Framingham Heart Study. This is the first study to identify a specific genotype associated with the tendency to occupy a leadership position. The results suggest that what determines whether an individual occupies a leadership position is the complex product of genetic and environmental influences, with a particular role for rs4950.     

Leading beyond the bottom line, Part 4. The questions it has raised

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.