Developing Physician Leaders for Successful Clinical Integration

By Carson Dye

Winner of the 2014 ACHE James A. Hamilton Book of the Year Award!

The changes coming from health reform legislation, cost reduction, work redesign, growth in physician employment, greater consumer involvement, the introduction of ACOs, and the emphasis on value-based purchasing are having a profound and long-term impact on healthcare. Clinical integration is a must, and inclusion of physician leaders is essential for successful clinical integration. For healthcare organizations to maximize their potential during this transition, effective physician leadership is needed more than ever.

Unlike other physician leadership books, this is an intensified examination of the development of clinically integrated organizations and the significantly expanded physician leadership role within them. Together Dye and Sokolov evaluate multiple clinically integrated organizations, clinical models, business models, and techniques to involve physicians to a greater degree. They also offer insights and suggestions on the cutting-edge topic of clinical integration and explore in detail the role physician leadership will play in the future.

Themes include:

Making physicians key stakeholders in the clinical transformation, business modeling, and strategy development Identifying physicians who have a propensity for leadership Understanding the difference between management and leadership Addressing issues physicians face as they make the transition from clinical roles to leadership positions Embracing clinical integration—why this new entity calls for greater physician leadership and how to build a successful clinically integrated organization Learning from case studies and practical approaches Creating leadership development programs with an emphasis on the experiential side of leader development Examining on the significant impact of physician leadership derailment as compared with other leaders

• Language: English
• Publisher: Health Administration Press
• Release date: Feb 21, 2013
• ISBN: 9781567935578

Book preview

ACHE Management Series Editorial Board

Natalie D. Lamberton, Chairman

The Medical Center of Aurora

Christina R. Campos

Guadalupe County Hospital

Jaquetta B. Clemons, DrPH

Christus Spohn Health System

David A. Disbrow, FACHE

University of Cincinnati

Scott A. Haraty, FACHE

North Chicago VA Medical Center

Virginia Larson, FACHE

Albert Lea Medical Center–Mayo Health System

Paul A. Milton, FACHE

Ellis Hospital

Greg Napps, FACHE

Culpeper Regional Hospital

CPT Joseph L. Sanchez Jr.

US Air Force

Megan Schmidt, FACHE

Select Specialty Hospital

Arthur S. Shorr, FACHE

Arthur S. Shorr & Associates Inc.

Janet C. Sternberg, FACHE

Huron Medical Center

DEVELOPING PHYSICIAN LEADERS FOR SUCCESSFUL CLINICAL INTEGRATION

Carson F. Dye and Jacque J. Sokolov

Your board, staff, or clients may also benefit from this book's insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424–9470.

This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the authors and do not represent the official positions of the American College of Healthcare Executives or the Foundation of the American College of Healthcare Executives.

Copyright © 2013 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Dye, Carson F.

Developing physician leaders for successful clinical integration / by Carson F. Dye and Jacque J. Sokolov.

   pages cm

ISBN 978-1-56793-554-7 (alk. paper)

1. Physician executives. 2. Hospitals—Administration. 3. Leadership. I. Sokolov, Jacque J. II. Title.

RA972.D94 2013

362.17'2—dc23

2012036073

™

Acquisitions editor: Janet Davis; Project manager: Amy Carlton; Cover designer: Marisa Jackson; Layout: Virginia Byrne

Found an error or a typo? We want to know! Please e-mail it to [e-mail], and put Book Error in the subject line.

For photocopying and copyright information, please contact Copyright Clearance Center at www.copyright.com or at (978) 750–8400.

Health Administration Press

A division of the Foundation of the American

   College of Healthcare Executives

One North Franklin Street, Suite 1700

Chicago, IL 60606–3529

(312) 424–2800

For my family

—Carson F. Dye

To my loving family, Mitzi, Mariel Francesca, and Ariana Isabel, and to the previous generation of healthcare executives, both physicians and nonphysicians, whose shoulders I stand on

—Jacque J. Sokolov

Contents

Foreword

Preface

Acknowledgments

Introduction

Part I: Making the Case for Greater Physician Involvement

1.    Physicians

2.    Physician Engagement and Leadership: What Does It Mean?

Part II: Physician Leadership—First Steps

3.    What We Have Learned

4.    Identification of Physician Leaders

5.    Physicians in Management and Leadership Positions

6.    The Vice President of Medical Affairs Position and Its Transition

7.    The Transition to Leadership and Management

8.    Covering the Basics

Part III: Future Steps

9.    The Changing Healthcare Environment and the Clinical Integration Imperative

10.  Building a Clinically Integrated Organization: A How-To Guide

11.  The Enterprise Quality Plan: Structure, Function, and Physician Leadership Opportunities

12.  How to Assess and Select Physician Leaders

13.  Education of Physician Leaders

14.  Case Examples of Physician Leadership Development Programs

15.  Avoiding Derailment

Epilogue: A Note from the Authors

Appendix A: Evaluation Tool—Physician Leadership and Involvement Program

Appendix B: Clinical Integration Readiness Assessment

Appendix C: Letters

Appendix D: Physician Candidate Evaluations

References

Index

About the Authors

Foreword

Today, more than at any time in American history, healthcare is at a crossroads with respect to its future and sustainability. The Patient Protection and Affordable Care Act (ACA) of 2010 is a game changer that will require all healthcare providers to rethink traditional strategies and approaches to operational management and to reinvent the delivery of healthcare in these unpredictable and turbulent times to survive.

Carson Dye and Jacque Sokolov, MD, through their book Developing Physician Leaders for Successful Clinical Integration, provide the healthcare executive with a roadmap to navigate these new waters by integrating physicians into the very fabric of the organization. With this integration, the influence of physicians can be real and meaningful and can ensure that physicians take ownership and pride in their healthcare delivery setting and do not simply respond as renters. This book will help healthcare executives determine their readiness for accepting physician leadership and understand the value physicians bring to new roles within healthcare management.

More than ever before, the traditional approaches to cost management, patient safety, quality improvement, and the patient experience—all affecting pay for performance—require a divergent direction that brings physicians into true partnership. Giving physicians leadership opportunities helps to set the stage for their input into governance, strategy, policy development, management, and significant engagement in operations, all affecting how we do business in these undefined times. If our goal is to be ready for whatever comes our way regarding healthcare reform, we must be prepared to engage physicians in meaningful leadership positions and develop them accordingly.

Transition and ambiguity are our collective futures; one size does not fit all. And yet we must create organizational values that are inclusive and nimble and acknowledge we are on this journey together—together we succeed or fail. By embracing true physician leadership we can build a culture of collaboration like never before for the benefit of the patients and community we collectively serve.

Steven A. Fellows, FACHE

Executive Vice President and Chief Operating Officer

Cottage Health System

Santa Barbara, California

My career journey started in high school in Tipp City, Ohio, when I decided to make premed my college major. This decision was a result of two major influences in my life—sports and my family physician. This physician served as the team physician for the high-school basketball team, and seeing him in these two roles made me want to be just like him. His desire and interest in helping people and giving back to his community was truly remarkable.

Being involved in sports also helped me understand and appreciate the need for a team in order to win. In team sports, individual success has minimal impact on the ultimate goal, which is to win a game or a championship.

After attending Valparaiso University on a basketball scholarship, I was fortunate to be accepted to The Ohio State University Medical School. From there I was chosen to be a resident in the family practice residency at Miami Valley Hospital in Dayton, Ohio. Following residency, I joined a two-man family practice group in my hometown. My family's physician, my role model, had been a partner in this practice. Unfortunately, he had died two years earlier because of a progressive neurological degenerative disease. Starting my career as a practicing physician by replacing the man who had been my role model was deeply meaningful to me.

I practiced clinical medicine for 17 years, including serving as a team physician for my old high school. My physician executive duties began when I was elected chief of staff at Upper Valley Medical Center at the age of 38. I felt ill prepared for this role, and, like many physician leaders, I jumped in and learned—sometimes the hard way—by experience. My biggest lesson was that getting other viewpoints and opinions is helpful in difficult situations. I also learned that the clinical staff members could exert a strong influence on each other that was sometimes more effective than top-down decisions.

The CEO at the time recognized that physicians had little to no leadership training. He funded my attendance at seminars at the American College of Physician Executives. I found these meetings exciting, interesting, and thought-provoking, and I began to think I could have a greater impact on healthcare as a physician executive than I had as a practicing physician.

I became the medical director of the hospital's employed primary care group (after selling our practice to the hospital) in 1994, and became its first chief medical officer (CMO) in 1997. I was extremely fortunate to be given responsibilities in pharmacy and home health, which were beyond the traditional duties of the CMO or vice president of medical affairs (VPMA). From this experience, I learned about operational planning and the financial side of medicine. Most important, the CMO position gave me a seat at the table with the other senior executives. My opinion was valued and taken into account when the nonphysician CEO made decisions, and I realized that being asked for input before the decision had already been made was important to me.

I left my organization in 2000 to become medical director at East Jefferson General Hospital (EJGH) in Metairie, Louisiana, a suburb of New Orleans. I intended to be there two or three years and move on, but in August 2002 I was chosen as interim CEO. At that time, one board member made a statement that would stay with me forever: We, the board, have one employee—you. That statement quickly put things into perspective and made me realize that moving into the CEO position meant moving into new territory and vast responsibilities.

I am often asked if my long-term goal was to become a CEO. The answer is no. At the same time, as my career evolved and moved forward, I became convinced that physician leadership was vital for successful healthcare organizations. I do not think that every organization needs to be led by a physician; I do think that successful organizations need to have engaged physician leadership. I also believe that high-performing organizations have moved beyond thinking of physician leaders only in the traditional VPMA or CMO roles. As healthcare is rapidly evolving, physicians need to be directly involved with strategic and operational discussions and decisions. The life of a practicing physician is also changing dramatically. Not including physicians in key decisions is shortsighted and foolhardy.

Through basketball, I learned that building a strong team means placing less emphasis on individual accomplishments, much as physicians must learn to trade some of their independence for the greater goal. And based on my own career, I believe management and leadership educational programs are valuable, but they must be combined with real-life experiences for successful physician leadership. Carson Dye and Jacque Sokolov have written a book that echoes my conclusions about healthcare organizations and physician leaders. But their book has also allowed me to make new connections and develop new insights. In these pages you will find both great strategy and practical suggestions to enhance the role physicians play in leadership. Even those who believe they already get physician leadership will benefit from reading this book.

Mark J. Peters, MD

President and CEO

East Jefferson General Hospital

Metairie, Louisiana

Preface

The push toward population health, outcomes-based reimbursement, and greater accountability necessitate that hospitals groom physician leaders. How good a job do we do in training physician leaders? Do we pick out potential candidates and groom them?

—David Nash, MD, dean, School of Population Health, Thomas Jefferson University (Weinstock 2011)

A CLEAR LOOK AT A CONTROVERSIAL TOPIC

We present this book to you with great respect and humility. This topic is often loaded with strong emotion and passion. So many divergent views exist on the topic, some causing great divisiveness. We have engaged in many spirited and, at times, heated dialogues with both physicians and nonphysicians in the development of this book. We hope to present a neutral but strong clarion call for an enhancement of our industry's efforts to prepare and deploy more physician leaders.

We do not wish to be divisive, but we do make many evaluative and prescriptive comments in the book. We share these general thoughts with you the reader in hopes that you will understand our thoughts and approach as we crafted this text.

These beliefs and viewpoints shaped our thoughts as we wrote.

A TSUNAMI OF CHANGES MEANS DEMAND FOR PHYSICIAN LEADERS

We see more significant change in healthcare in the United States now than at any other time in history. Although this statement could be hyperbolic, we do believe it. We think the entire shape and form of healthcare delivery will be substantially changed in the next ten years. Although most of the changes are being driven by economic reasons, much of the transformation—and we do mean transformation—will be physician-centric.

We believe that quality has finally taken a front seat in the healthcare industry, and we contend this is a good thing. We see two drivers for this change: several Institute of Medicine reports (2012, 2006a, 2006b, 2003a, 2003b, 2001, 1999) and the determination by payers—and consumers—that they want more value for their dollar.

Because of this and several other factors, we strongly feel that there will be an enormous demand for more physician leaders who are better trained, better educated, and better prepared to lead.

CLINICAL INTEGRATION

Healthcare has been on a path to clinical integration for decades, but the market forces driving us in that direction—fueled by economics, reform, and patient and payer preference—are stronger than ever. Back in the day—the 1980s and 1990s, if you remember that particular part of way back when—the talk was about integrated delivery systems and pay-for-performance programs. Now that emphasis on providers working together on the value of the services they provide has matured. Now not just the means of delivering care services must be integrated, but the services themselves must be coordinated toward a result, not an amount required to make a profit. Now providers must be paid not just for meeting evidence-based care guidelines but for providing value for the money that payers and plan sponsors spend. And we must strongly suggest this change is not just Capitation 2.0. We feel that capitation was an economically driven concept, while this new clinical integration world is physician-centric.

That distinction means physicians and hospitals—and all the ancillaries, devices, and diagnostics they have at their disposal—must be better aligned across broad clinical categories if providers hope to offer the type of value-based care that payers and patients demand. And that means physicians must step up and assume leadership roles in healthcare organizations that were heretofore considered the exclusive purview of career business executives. Physicians' hard-earned understanding of what works and what does not—and at what cost—from a clinical patient care perspective is the driver of the new normal in healthcare. Meaningful clinical integration is not just a catchphrase or a buzzword. It is a roadmap to survival.

PHYSICIAN LEADERSHIP DEVELOPMENT EFFORTS ARE RAPIDLY CHANGING

We feel that even the best efforts at creating physician leadership development programs in the past were poor compared to the better-focused approaches that are beginning to be used today. We believe differences exist between management and leadership positions, which explains part of the problem with physician leadership development activities. We do not feel, as some do, that management is bad and leadership is good. Rather, some positions involve mostly management, some involve mostly leadership, and some are a blend of both. We feel these considerations are important in physician leadership development, and we highlight these differences throughout the book. We feel as well that current efforts are beginning to recognize the unique skills that physicians bring to both disciplines (management and leadership) and the critical role those skills play in creating and managing a clinically integrated organization.

JUMPING IN

We recognize that among the challenges and difficulties in writing this book is the fact that organizations are at many different stages in physician leadership and involvement. Some are advanced; some are just beginning. Some still have traditional medical staff models, while others have scrapped those models entirely. Some have all employed physicians and some have few. Some focus on grooming physician leaders rather than physician managers, and some recognize that both are crucial to the future functioning of a healthcare organization.

Moreover, we recognize the many divergent views on this topic. Engaging physicians in the development and management of a clinically integrated healthcare organization is fundamental to the success of every provider organization in this country. But not everyone is ready to embrace tomorrow and leave yesterday behind. We have tried to focus on the future, on the critical need to bring physicians into the leadership loop. We ask you, the reader, to approach our material with an open mind and a seeking spirit. We do not have all the answers. But we feel this book will serve as a good guide for exploration.

Ultimately, we hope to bring value to our industry.

Thank you for reading.

—Carson Dye and Jacque Sokolov

Acknowledgments

My executive search work lets me meet many great leaders and learn about many great organizations. In some respects, if I just listen and act as a sponge, I pick up hundreds of books' worth of excellence and impact leadership. I have interviewed and visited with so many physician leaders and executives over the years and have been truly enriched by their visions, accomplishments, thoughts, and experiences. In reality, I owe acknowledgments to far more people than I could list. So, first of all, to those who are not listed but from whom I have gained in knowledge and perspective, thanks.

Second, I want to acknowledge several doctors who have touched me along the way and given me insight and thoughts that have helped stimulate many of the ideas in this book. To begin with, I must lift my hat high for Dr. Greg Taylor. Greg and I taught an American College of Healthcare Executives course on physician leadership for several years in the 1990s, and he was a great partner. Like many great physician leaders, Greg has moved higher in his own physician leadership career and is a chief operating officer and a Baldrige examiner as well as a great friend. I make special note of my friend and fellow Health Administration Press (HAP) author, Dr. Ken Cohn. Ken does great work in helping others work collaboratively with physicians; he is constantly adding to our insight about physician leadership. Dr. Scott Ransom, CEO of the University of North Texas Health Science Center, has been a great friend and colleague over the years. A former president of the American College of Physician Executives, former chief medical officer and chief quality officer, and a former executive search colleague, Scott has given me much to think about as I have pondered the leadership roles of physicians in healthcare. Dr. Mark Peters, who was so gracious to write one of our forewords, is owed a note of thanks as well. I have observed and learned from his leadership over the years. I also thank the writer of our other foreword, Steve Fellows, another HAP author and an individual who has a great record of positive relationships with physicians. He truly respects the role physicians can play in leadership. It has also been an honor to get to know Dr. Mark Laney and gain from his viewpoints on physician leadership. I also owe thanks to a number of physicians with whom I have interacted at various meetings of The Healthcare Roundtable and elsewhere. While I hate to overlook anyone, I would include in that list Drs. Steve Markovich, Dave Kapaska, Imran Andrabi, John Byrnes, Kathy Forbes, David Tam, Cliff Devenny, Tom McGann, Courtenay Beebe, Dee Russell, John Fortney, John Kosanovich, Stacy Goldsholl, Ronnie Brownsworth, Robin Ledyard, Bill VanNess, and John Paris. These physicians likely do not know the influence