Be positive--it's a necessary strategy. (Career Rx).

It's one of my goals for this column to identify trends in the industry, and to pair observations with suggestions for addressing issues and problems. With success stories few and far between, the turmoil has been relentless. It was heartening to see in a recent issue of Modern Physician that a physician group in Tucson has achieved ongoing autonomy and success on their own initiative. (1) I hope that 1999 will yield many other stories of endeavors that are heading in a positive direction and that will endure.

As a search consultant, I know these are grim times when even my strongest candidates tell tales of organizations with serious fiscal and strategic challenges, although those health care systems may have had high revenues and large numbers of covered lives. Relations between physicians and administration (always historically strained) are stretched more than ever. Fostering cordiality in this taut interface is usually the purview of hospital- or system-based executives. Physicians, never the most trusting of souls, are increasingly pessimistic, and some of the strongest practitioners are leaving the clinical realm altogether.

The hallmarks of success

The high level of negativity prompted me to seek out and identify the factors and parameters that contribute to examples of success, which at least would include reasonable fiscal health and a focused organizational strategy. My observations are admittedly anecdotal, although a current analytic study supports them. (2) The hallmarks of success I have seen are:

1. Positive physician culture

2. Meaningful physician involvement in governance and top management

3. Stability and strong community roots

The first hallmark, positive physician culture, does not depend on what the name is above the door--Group, Hospital, IDS, or some other type of health care organization. What does matter is the positive culture within. Here's a working definition: A positive physician culture means the physicians understand why they are there (to provide care to patients), enjoy a healthy, competitive internal dynamic among themselves, and know they are delivering a high quality of care. Because of high professional self-esteem, their CME is likely to be in good order and their professional review process will have integrity and follow-through.

I'll admit there are not many, but some organizations do already operate at this level of physician accountability and professionalism. There need to be many more. I am not suggesting that all health care should be dominated and driven by physician issues and physician governance. Rather, I want simply to highlight the point that organizations that acknowledge their physicians this way are having greater success.

The second hallmark is meaningful physician involvement in governance and thus, ownership-whether emotional or actual equity. When an organization's physicians are deeply involved in strategic planning and setting policy, good things are occurring. We see this most commonly in large, physician-driven group practices. It is no coincidence that the Cleveland Clinic and the Mayo Clinic (both physician-driven and -governed organizations) enjoy superb reputations for excellence. But physicians can be involved in governance in acute-care provider settings, as well. One large delivery system in the Southeast that has a seriously positive physician culture is strong and successful. When I inquired about its governance, I learned that seven of the eight board members are physicians. (The eighth is the CEO.)

The third element is stability, related to community roots and rate of growth. Health care organizations are largely mission-driven, and the communities they serve know this at some deep level. Reputations are built slowly, over time, both by physicians and by acute-care providers. The value of reputation is best demonstrated in reverse--most health care systems that have come apart grew quickly and relied on size rather than on community reputation.

A new, multi-parameter study on Illinois health care systems published in the Journal of Healthcare Management supports my perceptions. (2) The study's key finding: The best fiscal performance is related directly to good physician/administration relationships, which translates into a positive physician culture, meaningful physician involvement in decisions, and community stability.

Putting it another way--success is most likely where physicians in the facilities are having professional fun, where freedom from negativity allows them to perform at their highest level of quality. They are not Pollyannas, these positive physicians. They still suffer with their patients who suffer, and they still agonize over equipment budgets and other needs. They still complain about things, and wish for more (or less) of whatever bugs them. The difference is, they don't let It get in the way.

When a positive physician culture takes hold, remarkable things can occur. In the best scenarios, physicians are deeply involved in strategic direction, as well as in practice. They are part of making the decisions, instead of merely grumbling about decisions made by others. An empowered organization does not happen in a moment or even many moments. Cultures--and culture shifts--are functions of time. They cannot be rushed nor forced, but they can be encouraged and enhanced.

Creating a positive physician culture

What could you do to help create a positive physician culture where you find yourself at the moment? Here are a few suggestions, based on my observation of what's working:

* Project high professional self-esteem and practice standards that others can emulate. Shun negativity.

* Examine the structures now in place where you are, and challenge those that appear to work against building a positive physician culture.

* Similarly, encourage any indications of positive development that you note. When your physician colleagues and management work together, spread the word of that success.

* Actively search out success examples in your organization's problem areas and involve your physicians in the quest. "Positivity" is as contagious as negativity, and it certainly feels better

Creating a positive physician culture if you don't have one (congratulations, if you do) may be the toughest task you ever undertake. It is a long-term, higher-plane leadership activity, more vague than your most immediate tasks, such as organizing the OB/GYN service or ensuring the good order of the QA initiative. But it is also likely to yield the most results over time, letting all of the day-to-day tasks be approached as parts of a bigger picture. I'm eager to hear your success stories, so please send me your brief account of what's working.

References

(1.) Cook. Bob. Blue Skies, Modern Physician. Jan. 1999.

(2.) Burns, L. Robert. Polarity Management Key Challenges for Integrated Delivery Systems. Journal of Healthcare Management. Vol. 44. Jan./Feb. 1999.

Mary Frances Lyons, MD, is a Senior Consultant at Witt/Kieffer, Ford, Hadelman & Lloyd in St. Louis. She can be reached by calling 314/862-1370, via fax at 314/727-5662. or via email at [e-mail]. Please fax or email questions that you would like addressed in this column to Dr. Lyons.