A seat at the power table: the physician's role on the hospital board.

Today's hospital board of trustees faces unprecedented challenges in the areas of quality, care delivery, financing, physician relations and information technology.

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More often than not, trustees seek counsel from members who are successful corporate and civic leaders, and philanthropists and activists who draw on their personal and professional achievements to help guide and define health care services in communities across America.

Indeed, it is predominantly the board's business dealers--and not its patient healers--who are reshaping the delivery of health care today.

What say physicians? With today's unprecedented challenges, it is imperative that physicians use their seats in boardrooms across America as pulpits to ensure their hospital embrace a vision of clinical excellence--a vision that physicians alone, as the guardians of patient and community health, can best articulate and advance.

Changing expectations

A hospital's board is responsible for the institution's performance and mission. It's true that physicians have always had a seat at the table, with most U.S. hospitals inviting one or more physicians to participate.

However, many doctors have traditionally and comfortably confined their roles to serving as ombudsman to the medical staff. They survey medical colleagues and report on the need for new technology, novel equipment or expanded services. In the boardroom they are a resource for fellow trustees, fielding questions about care quality and patient safety, and serving up a medical staff perspective on issues of the day.

It's time for physician trustees to move out of the comfort zone and into the power seat. They can and must do more to rally clinical and administrative troops, direct the discussion, mediate consensus and chart the hospital's course, which ultimately will lead toward improved community health.

Should they fail to embrace a more commanding role, it could prove hazardous to not only patient and community health, but also to the hospital's well-being.

Indeed, the men and women serving in today's medical boardrooms support a changing and more pivotal role for their physician colleagues. Just as passengers would not want an airline's chief financial officer to fly the airplane, hospital trustees want the care-delivery agenda piloted by those who understand it best.

Trustees appreciate that physicians are:

* Directors of quality and clinical performance

* Advocates for easy access and productive partnerships

* Overseers of reimbursement trends and sound finances

* Catalysts for collaboration

* Champions for IT applications

Board members want a physician peer to weigh in and to contribute to setting the agenda on quality, retention, reimbursement, cooperation and innovation, representing the perspective of the entire medical staff and guiding the way toward productive change and collaboration.

They understand that accomplishing the hospital's goals is dependent upon dynamic, mutually beneficial hospital-physician partnerships. And they want the physician trustee to lead the way.

Ruby slippers in hand

Like Dorothy from "The Wizard of Oz," who was slow to grasp that the power to return home rested solely within, physician trustees need to awaken to the realization that they have the wherewithal, clout and respect to lobby for the health needs of their communities and transform the delivery of services.

Their unique perspective counts, maybe more than any other, in devising strategies to safeguard quality, foster access to care and ensure appropriate utilization of services and technology.

Still, for all their collective insight and expertise, physician board members are sometimes guilty of falling short in a few key areas by not:

* Putting aside personal views to focus on a broader organizational picture

* Representing the needs of younger physicians or those outside their own specialty

* Understanding the operational complexity of the organization, and its facility, labor and information technology challenges

* Being sensitive to the burden of regulation and accreditation

* Grasping the full picture as it relates to the needs of the community served

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To help address these shortcomings, some experts are advocating for more formal ways (developing written position descriptions) to achieve greater clarity between the roles of those physician trustees who serve in the same capacity as any other board member, and those who are typically selected by the medical staff and serve ex-officio, usually because they are either the hospital's chief of staff or medical staff president.

Trustees and wannabes 

If you are a physician already sitting on a board, or a doctor ready for a leadership position there, take note of five critical areas where you can marshal forces to make a significant difference for your hospital and community. It requires educating yourself and your fellow trustees in order to drive your organization's conversation and decision-making ability.

Understand, too, that your job as trustee is to ask penetrating questions, delineate the outcome that is expected and ensure that the organization stays the course. You do not, and should not, dictate the course of action to meet the goals; that's management's job.

Directors of quality and clinical performance

First and foremost, the physician trustee should be the prime advocate for quality, improved patient care outcomes, patient safety and clinical care excellence. Be certain that you and your fellow board members thoroughly understand, and tenaciously address, these questions:

* What is the impact of transparency on our organization? Specifically, how will we respond to public reporting on our quality and outcome measures, what will we implement in the way of clinical improvements to stay ahead of public data releases, and where do we stand vis-a-vis payers, who need our data, and competitors, who look to capitalize on their own outcome achievements?

* How do our patients use public reported data to make health care decisions?

* initiatives such as Leapfrog or Bridges to Excellence?

* Have we assessed, for example, if our patient volume--from routine to complex cases--meets the six Bridges to Excellence primary quality attributes; that is, safe, effective, efficient, patient-centered, timely and equitable care delivery?

* Do quality measures include patient mortality, nurse patient index, nurse magnet status, and patient care coordination, as appropriate?

* Does the hospital use CareMaps, best practice protocols and clinical guidelines?

Advocates for easy access and productive partnerships

The physician trustee is a proponent for community, patients and providers alike. You and your board colleagues must set the tone, positioning your institution as consumer-friendly, responsive to patient and community needs, supportive and efficient for employees and providers, and easy to access for all. Use these questions to stimulate discussion and spark action:

* Are our constituents--patients, physicians, employees--satisfied? How do we measure their satisfaction? Are our scores where we want them to be? How do we communicate, celebrate and reward performance and leadership?

* How quickly can our patients get appointments, book surgeries/procedures or access ancillary services?

* Are surgeries and diagnostic testing procedures scheduled and coordinated for our patients or must patients navigate a maze of services and offerings independently?

* Are we the provider of choice for all referral sources in our community? Do we actively and swiftly facilitate physician-to-hospital and physician-to-physician referrals?

* Do we have minimal errors and complaints? Do we take prompt action on patient, family and referrer incidences and complaints when they occur?

* Should we adopt innovative customer service programs such as same-day appointment scheduling, patient care coordination, online history and physicals, medical record access by patients and provider/patient e-mail?

* Are we prepared for the increasing demands for service excellence that aging baby boomers will make?

* Is there a better way to manage chronic care by reexamining ambulatory strategies and tactics? Can we develop and implement health systems to screen for, and prevent, chronic disease and illness?

* What will be the direction and pace of change in our organization?

Overseers of reimbursement trends and sound finances

Hospital management is responsible for, and usually quite savvy about, reimbursement, billing and financing. However, physician trustees must be well versed in the two major environmental trends affecting patients, providers and hospitals alike: pay-for-performance initiatives and consumer-driven health plans and health savings accounts.

Insurers drive pay-for-performance criteria in order to tie reimbursement to quality improvement. Ask your board colleagues these tough questions:

* Are we knowledgeable about initiatives among our payers?

* Against what criteria are our physicians measured and are there additional performance measures we should anticipate?

* How can we help our providers and clinicians improve their performance?

Employers are leading the charge to empower employees to comparison shop and make health care choices based on costs and customer satisfaction. It's a fact: consumer driven health plans and health savings accounts are shifting control of purchasing decisions and dollars from insurers to patients.

* Are we ready to respond to the resulting increased consumer expectations?

* Are we set up, as an organization, to help consumers easily compare and choose our services over competitors?

* To bolster our cost-effective position, have we ensured that expense management strategies are sound from both a quality and cost standpoint?

Catalysts for collaboration

While physician trustees contribute to the board's agenda--as directors of clinical performance, advocates for access and partnerships, and overseers of finance--they should lead in the development of strategies to strengthen hospital/physician collaboration.

Today's hospital/physician collaboration agenda has two components.

The first is to redefine the rules of engagement. The changing medical landscape is forcing trustees and others to reexamine the traditional relationship between hospital and physician. Authors and governance experts James Orlikoff and Mary Totten suggest that board members and physician leaders jointly consider these questions:

* What terms would we use to describe the current relationship between the hospital and physicians and how can we achieve the relationship we want?

* How would we characterize the traditional social contract that existed between the hospital and physicians?

* What is changing, what should we preserve in this contract, and what should we rewrite?

The second agenda involves economics and business

* Will our hospital partner with physicians to deliver branded services? Facilitate joint ventures?

* Will the hospital offer special incentives and support for physician practices, including recruiting primary care and specialty physicians into our community, employing physicians and offering practice management services--from basics such as billing and malpractice insurance procurement, to more sophisticated offerings such as quality management/reporting and electronic medical record acquisition and support?

Champions for IT applications

It's a wild Wi-Fi and Web-based world today, where doctors can provide care and consults off-site, from remote locations, and patients can tap into portals and pages that offer health advice and diagnostics.

If you don't speak the language or use the tools, or you haven't mastered the technology, it's time for a crash course. As physician trustees, you must ride and promote the wave or risk falling behind with an up and coming generation that will soon receive all the info it needs via cell phones.

The Partners Health Care System in Boston has adopted five signature initiatives, each supported with information technology (IT) tools:

1. Investing in quality and utilization infrastructure

2. Enhancing patient safety by reducing medication errors 

3. Enhancing uniform high quality by measuring performance to benchmark for select inpatient and outpatient conditions

4. Expanding disease management programs by supporting activities for patients with chronic illnesses

5. Improving cost effectiveness by tracking and managing utilization trends and analysis of variance

Physician trustees must serve as power brokers to vet their own hospital's IT initiatives from the provider perspective. Make sure you can ask, and respond affirmatively, to the following:

* Where are we in introducing, implementing and/or expanding our electronic medical record capabilities?

* Is the clinical information supporting our IT tools accurate and up-to-date?

* How will our IT tools allow for improved care coordination between the hospital and its physicians?

* How will we use our IT tools to manage our costs? What is the role of our physician community?

* How will our IT tools help involve our patients in proactively managing their care and in strengthening the patient/physician relationship?

* How will we use IT to develop our own quality reporting systems to preempt external source reporting?

* Have we adequately funded the venture to ensure our physician community can acquire, install, integrate and optimally utilize the IT tools?

* Have we seeded the transition from paper to electronic tools with enough capital to train physicians and staff and to provide transition support?

Ensuring and promoting preeminence 

Physician trustees, as guardians, stewards and directors, are in a unique position to shepherd health care systems and organizations through some of their toughest medical, operational and financial challenges to date.

It's time for setting bigger goals with broader horizons, for expecting much of self and peers, and for motivating all to make the best choices for improved patient and community health. By asking the right questions and investing in the right personnel and resources, you can help shape a preeminent position for your organization.

Jayne Oliva is a principal with The Croes*Oliva Group, a medical group management consulting firm, specializing in developing outpatient operational improvement plans for physician practices at major academic medical centers and integrated delivery systems throughout the U.S. She can be reached at [e-mail]. Visit the firm's website at www.croesolivagroup.com.