Paving the Way for a New Era of Clinician Leadership
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Health care is under renovation in our country. As focus shifts to the Triple Aim of care, health and cost, the barriers between the clinical and business sides of health care are coming down, creating a need for a new leadership structure in which clinicians must play an increased role.
Despite the central role physicians play in delivering health care, only 10 percent of senior hospital executives are physicians. In the past, physician leaders have largely focused more on clinical matters (such as credentialing and peer review) and less on business operations such as strategy formation, resource allocation, budgeting and human resources. While nurses have long taken lead roles in the day-to-day business of delivering patient care in hospitals, they are still underrepresented in health care leadership, especially considering they make up the largest portion of the health care workforce.
All this is poised to change. As the economics of health care shift from volume to value in the second curve of health care, the separation between the clinical and business sides becomes artificial and counter-productive.
There are other factors that play a role as well. Physician employment has risen by more than 54 percent since 2000. Joint ventures between hospitals and physician practices has increased from 19 percent in 2004 to 29 percent in 2013. This creates more opportunities for clinicians to become engaged as organizational leaders. But the need for clinician leaders is the result of more than hiring patterns or mergers and acquisitions.
“It’s changing because the nature of what we do in health care organizations is changing,” says John R. Combes, MD, American Hospital Association (AHA) senior vice president and chief medical officer. Instead of focusing on the number and types of services delivered, reimbursement is shifting to outcomes: how well and how efficiently is the care delivered. “There needs to be a coming together of the management staff and the clinicians so that we can manage the clinical enterprise more effectively, especially in a fixed payment environment.”
This is “a different conversation about how we pay for care, and we can’t have it unless we’re talking with clinicians,” says Pam Thompson, AHA senior vice president for nursing and chief executive officer of the American Organization of Nurse Executives (AONE), an AHA affiliate. She points to one of the foundational principles of performance improvement: It’s best to ask the people closest to the work to design, test and implement the solution to a challenge.
“Clinicians know when to appropriately use resources to benefit the patient,” says Combes. “They understand the work flow and the use of the medical record for clinical communication, not just charge capture. They bring a perspective of what the patients’ needs are and act as a patient advocate in a system where there are many competing needs.” Someone with a business background can determine which treatment costs less, but it takes a clinical perspective to determine which is most cost effective for actual patients.
In fact, effective leadership may need to more closely mirror the interdisciplinary clinical teams that deliver comprehensive, effective care to patients. The same types of relationship and communication skills that make solid team members for patient care can also form the foundation for great leadership, especially in an environment of change.
Most clinicians need additional training in these skills for effective leadership in a world where clinical and business issues intersect. Medical and nursing schools don’t include formal business training, economics and strategic thinking. Thompson points out that clinicians are trained to answer questions, but the key to leadership is often knowing how to ask the right questions.
But just as clinician leaders need to learn these business concepts, Combes adds, non-clinicians have to take time to understand the clinical side, such as, “how the work flows, and the issues around professionalism and clinical autonomy (which is really about putting the patients’ needs first) despite the financial pressures on the organization,” says Combes.
The best way for this interdisciplinary cross-training to take place is often right at the hospital or health system, in the teams that are working together every day. “You can’t read a book, and step out and function as a collaborative team or be a leader,” says Thompson. “You have to live it.”
A common training method is to form dyads or triads of leaders from the clinical and administrative sides of health care. The first step is “to get to know each other, work with each other, learn about how they interact with each other,” says Mo Kasti, founder and CEO of The Physician Leadership Institute. Strengthening those relationships allows the teams to develop a sense of common purpose and sets the stage for successful problem solving.
Instead of pulling potential leaders from the working environment, interrupting productivity to ship them off to a conference, Kasti recommends working “with the team in their own backyard” on real-life challenges, such as unnecessary readmissions, increasing referrals or improving the patient experience. “They learn about the issue and the complexity of it, and they work through that,” Kasti explains.
Hospitals and other health care providers that fund this kind of training find the rewards are well worth the investment. Because real-world problem solving is built into the training, the first benefit comes from the resultant solution and its implementation. The clinicians involved in finding the solution are then best able to spread the word and the concepts to their peers in other departments. Exercising their “engagement muscle,” Kasti says, gives teams confidence to take on other challenges and inspires other teams to develop their own performance improvement projects, resulting in a cascade of new ideas and innovations. And then, there are the intangible benefits, such as a better learning environment with tighter teamwork, improved trust and renewed energy and passion for patient care.
“In the long run, it’s the best thing for the patients,” says Combes.
