I don’t think I’ve written about this topic before. I guess I kinda thought it went without saying. But after speaking to, and meeting with, a variety of physician leaders this past June, I was struck by their general lack of input, or their limited roles as leaders, in many of the health systems represented at this event. Now, that’s not to suggest there is no physician input in the organizations present at this meeting. But, in many instances it appeared that the participation and thought leadership were rather myopic and confined to, say, comp. In other words, there seemed no, or limited, contribution on other important areas of their healthcare organizations. I’m not saying that this is rampant. But at this event it seemed…symptomatic…of a greater issue. And, to be fair, I’m not suggesting that I had a good sample size and a controlled study; but, sometimes anecdotal “research” is just as indicative.
To level set, let’s be clear; just because you’re a physician doesn’t mean you are, or should be, a “physician leader.” As I like to say, just because you’re a good widget maker does not mean you know how to run the widget factory. But there are physicians who have aptitude or who seek leadership education to enhance their career portfolio so that they can participate in the decision-making of their organizations. Good, sound, physician guidance goes a long way to improving care delivery, system operations, clinical quality outcomes, and clinician satisfaction. So why are some systems reticent to include providers in senior leadership roles? Well, hard to say; territorial? Lack of trust? I’ve always been a believer in surrounding yourself with the best people and, given declining post-Covid margins, you’d think the non-clinical powers-that-be would scratch their communal heads and re-think their senior leadership construct and decision making.
Figure 1 below, while a generalization, is directionally appropriate.
Figure 1
Lil org structure
Our fictional organization chart (Figure 1) delineates, on the left-hand side, the health system senior executive level engagement including the entire C-suite. Theoretically, all of the non-clinical folks (In/out patient exec directors, Administrators, RNs, etc.) report up to the “Leadership” level in some manner. Let’s say that the “Leadership” committee consists of four (4) selected senior leaders in the health system. Adjacent to the “Leadership” box I’ve inserted a Physician Advisory Committee, or PAC, that is comprised of, in this example, three physician leaders (Docs 1 – 3) representing a bevy of specialties and the advanced practice professionals (APPs) within a health system. Via the “Exec” committee, the three-physician PAC works with the four member non-clinical “Leadership” team on issues near/dear to the health system that are then funneled up to the C-suite approval/execution. The PAC aggregates input from clinicians and works, in a defined dyad model, with “Leadership.” The use of Figure 1, while broad, is meant to drive visual context of clinician involvement at the health system via some sort of defined structure; e.g., give the practitioners a seat at the table. I’d be so bold as to suggest that Figure 1, though generic and overly simplified, can be applied in virtually any setting. The parameters and structure can be defined and scaled depending on the system size, provider numbers, etc. The rate limiter, honestly, is systemic inertia.
Why engage physicians at an executive level? Well, here’s a pithy (non-exhaustive) list:
· Engagement by/with cohorts and constituents:
Deployment of engaged physician leaders (PAC or specialty designees who “get it” (as we non-clinical folks say) can assist health systems in cementing the bond between/with the system and its clinicians
· Compensation:
Educating PAC leadership about comp plans, market limitations, obtaining feedback from impacted clinicians, etc., and obtaining their buy-in/ownership goes a long way to driving cohort understanding/adherence
· Some basic rules:
Provide input and considerations re: rules for clinic operations; policies and procedures, office hours, etc. Working with clinicians on level setting means they have a dog in the fight
· Fundamentals of the organization:
Clinicians have boots on the ground knowledge about care delivery; hard/soft needs, how the EMR impacts their lives/care, patient schedules, comp drivers (like wRVUs), etc. They can provide unique insight into operational needs
· Thoughts/input re: quality measures and metrics:
I’m sorry but C-suite folks, unless clinicians, generally don’t know what goes into point of care delivery decisions. As the world moves towards “value-based care” (however you define that – let’s call it “repeatable quality outcomes at a managed cost”), it’s crucial to involve clinicians in “global” care models, VBC, etc. This can drive outcomes, both clinically and, one hopes, financially. That said, clinician partners should not have carte blanche to do what they want (see “Some basic rules” above)
· An honest broker (or brokers):
Offers constituent clinicians faith that they are being heard, have a seat at the table, and are valued. They might not agree with decisions but at least they’re getting an ear
PAC example: in my recent history I worked with small health system (+/- 150 clinicians) that was losing $400,000 per provider per year. In the aggregate, there were, as you might imagine, a variety of structural and operational issues. But a priority was addressing the lack of leadership with the clinicians. Essentially, all clinicians and clinics were “empowered” to do what they pleased. Clinic office hours varied from clinic to clinic, in some clinics physicians decided whom they would and would not see. Net/net, as the system grew via acquisition or partnership, the operations devolved into a menagerie of bad (or no) policies/decisions that were given cancerous purchase causing the infrastructure to bend. In working with C-leadership we determined that a stop-gap measure needed to be deployed to begin utilizing physicians to drive the change and betterment of the system. An intimate interim group of dedicated and invested doctors was selected to begin the process of helping to right the ship while a formal PAC (with defined tenure, goals, mission, etc.) was crafted. As you might imagine, the project did not provide an immediate return. However, within one year the system had cut their per provider losses to $100,000 each. Six months after that the physician enterprise (exclusive of the health system/hospital) was break even. Was this purely due to physician input? Probably not. But clinician participation brought tremendous progress toward ensuring all hands were rowing in the same direction and proved to the clinicians that management did indeed value their efforts and input.
When we stop treating clinicians like widget makers and both foster managerial education and the utilization of provider clinical skills in improving health systems, outcomes and the elusive cost containment goals grow more tenable.