Leadership is the key to chief medical officer success. (The Evolving Role of the Physician Executive).

TWENTY YEARS AGO, WHEN a hospital established a medical director position, the goal was to place a physician on the senior management team who would be the liaison between the administrative and medical staff, keeping all parties informed and assuring that decisions included a clinical perspective. The medical director or vice president of medical affairs assumed differing levels of responsibility and management duties depending on the support of the hospital's CEO and the board and medical staffs commitment to the concept of a physician in a leadership role.

Managed care organizations had a place for medical directors from the beginning as a liaison between the plan and the physicians in the community. Self-governed group practices tended to use one of their own physicians to serve as intermediary, as well as to improve communications. All of these physician executives were also responsible for the utilization review and quality of care functions, and these positions increased in levels of responsibility as the organizations grew and the marketplace became more complex.

The Physician Executive Management Center conducted a study in 1998/99 of 1,500 physicians serving in senior medical management positions to learn about their perceived value to their organizations. They were asked to identify the top two services they provide. More than 350 chief medical officers in systems, hospitals, group practice, and managed care organizations responded. providing an excellent view of the physician executive in full-time leadership positions.

Greatest value

Senior physician executives believe that the greatest value they provide to their organizations is their accumulated knowledge and experience--both in medicine and management. This medical management expertise is considered the key advantage of serving on the senior management team in helping to shape the organization's decisions and direction, and in planning and managing clinical affairs. Respondents also cited their leadership role and serving as a liaison for the medical staff or the physician practitioners in the community as a critical aspect of their position.

The survey results reinforce the importance of a solid clinical background for physician executives. The time spent as a practitioner and the necessary clinical training is a prerequisite for being accepted as a leader among other physicians and being seen as a credible member of the management team. Even with the trend of pursuing advanced management degrees, physicians also need the grounding of clinical experience to be successful in a senior management position in a health care delivery organization.

Functions related to managing the organization and day-to-day operational decisions were cited most often as valued services by physician executives in managed care organizations and group practices and only rarely by those in health care systems. Managed care organizations and groups typically have smaller management teams and the medical director must serve in an operational role more often than in a hospital or system environment. Also, since groups and managed care organizations are on the forefront of primary care delivery, the medical director would be the logical manager to oversee the operations of medical delivery and to provide direction to the physicians.

Personal values and characteristics were also considered important. About 10 percent of respondents cited characteristics such as judgment, loyalty, rational thinking, common sense, ethics, and integrity as the most valued services they provide. Here, we see an example of the value of the profession based on the physician and his or her reputation, rather than on the work that they do on a daily basis.

The medical director's role in quality management was rarely cited in the value equation. This represents a change in the nature of the position-the responsibility for overall quality of patient care likely continues to fall under the purview of the chief medical officer but is delegated. In group practices, no CMO said that quality management is one of their top two valued services.

Most enjoyed

We also asked chief medical officers what parts of their jobs they enjoyed the most. The number one response was working with the physicians on the medical staff and in the community. This includes the day-to-day involvement as a leader, as a mentor and educator, and overall as a liaison to the organization's practitioners. A closely ranked activity that respondents cited was management duties, such as daily operations and problem-solving, implementing new programs, negotiating, and meeting the challenges of managing in a complex environment.

If these physicians are correct about what is valued in their organizations, they are the right people in the right jobs. The activities respondents most enjoyed were the same as the functions they believe are of highest value to their organizations. So, they are doing what they like to do, and what they do is good for their organizations.

Beyond the interpersonal physician-to-physician activities, they often selected detailed duties and tasks as those they enjoyed, such as clinical studies, data analyses, credentialing, and operational management functions. Strategic planning and the creativity and innovative thinking inherent in the process were also considered rewarding. Most professionals would rank planning high, so this is not a surprise for physician executives.

Physician executives in hospitals and systems rated working with doctors as most rewarding, while group practice and managed care physician executives ranked management activities highest. Hospital and system chief medical officers seem to be more closely tied to interpersonal relationships with physicians and other administrators, mentioning team building and consensus building more often than their colleagues. Managed care respondents prefer operations and quality management. Both managed care and group practice physician executives enjoy the marketing aspects of their jobs, including public speaking and working with clients, an activity not often mentioned by those in hospital environments.

Conclusion

After many years in the making, the medical director position, by whatever title, continues to meet the initial objective of the position's creation. This can certainly be considered a success story for the profession--physician executives have met the industry's expectations for leadership. Interestingly, while the profession is truly evolving, some things remain the same year after year.

RELATED ARTICLE: 1998/99 SURVEY OF PHYSICAN LEADERSHIP

The results of the survey are included in The Physician Executive Compensation Report: 1998/99 Survey of Physician Leadership, available to ACPE members for $100 and non-member for $150 by calling 813/963-1800 or via email at [e-mail].

WHAT ARE CEOs LOOKING FOR IN CHIEF MEDICAL OFFICERS?

In my travels around the country and in conversations with medical directors and non-physician CEOs who work in various settings, I sometimes find that chief medical officers are confused about what their bosses think is most important for them to be doing. I interviewed three chief executive officers of large integrated delivery systems and asked them what they are looking for in their chief medical officers in the way of business skills, communication skills, and personal traits.

Susan Savard

CEO of The Nalle Clinic A large multispecialty group practice in Charlotte, North Carolina 

WHAT ARE THE MOST IMPORTANT SKILLS FOR A CHIEF MEDICAL OFFICER?

Certain business skills are important: an understanding of finance, an ability to take the lead in strategic planning and help clinical departments develop and implement their business plans, an overall understanding of compliance issues, being the leader of continuing quality improvement, the ability to manage growth. My Medical director and I have to serve as navigators, while our various boards are pilots. Of all of these business skills, strategic planning is the most important and being able to convince fellow clinicians that planning is essential.

Most small practices do little or no planning. Physicians just don't think about it. A large organization like ours will go nowhere unless we constantly look at where we have been and decide where we want to go. The chief medical officer must develop an understanding that most problems in the organization are system problems, whether they are concerns about billing, collections, scheduling, telephone service, or something else.

WHAT ARE THE MOST IMPORTANT INTERPERSONAL AND COMMUNICATIONS SKILLS?

The successful medical director must undergo a shift in thinking and not continue to think only like a physician. He or she has to know the difference between what is important personally and what is important to the organization. The CMO must operate as a businessperson and understand the goals of the business partner in this case, PhyCor. The physician executive is a culture broker and leads the shifts in the organization s behavior that are necessary for it to be successful in a changing marketplace. The behavioral shift may be something as simple as a change in scheduling or as com plex as a greater focus on service. The medical director must also understand that he or she, like the CEO and other administrators, serves many masters.

The chief medical officer must provide proactive leadership and lead the physicians to stop acting independently. He or she needs to provide education to the doctors to help them achieve desired behavior change, whether it is changes in practice patterns, dealing with support staff and patients, or whatever. He or she must be a risk taker.

The successful CMO should be willing to deal with conflict and be a mediator and negotiator. He or she has to be able to give and accept feedback and require the doctors and staff to be accountable. Additionally, the CMO must develop and implement an effective performance evaluation system and teach the associate medical directors or department chairs how to do one-on-one performance evaluations with their peers.

He or she needs to constantly develop clones within the medical staff. A large group practice can never have too many physicians who are interested in some management and leadership responsibilities. This means that the chief medical officer is always mentoring.

The medical director s success depends on relationship building, both inside and outside the organization. In addition, he or she must have community focus and be looking for ways that the organization can serve the community.

Finally, the medical director should have a strong patient focus. He or she must take the lead in seeding that care management plans are developed so that patients with congestive heart failure, diabetes, and other chronic problems get proper attention before big problems arise that result in costly intervention and hospital care. The CMO carries the flag for better service because as reimbursements become fixed and quality of care becomes a given, service will be the only differentiator between one provider organization and another.

Tom Revels 

CEO of Presbyterian Health System A large multihospital system in Charlotte, North Carolina

WHAT ARE THE MOST IMPORTANT SKILLS FOR A CHIEF MEDICAL OFFICER?

The medical executive needs to have a macroeconomic understanding of the dramatic changes in marketplace foroes: (1) in reimbursement and (2) in the demands and expectations of payers, the government, employers, and the individuals receiving care.

The physician executive must be an expert at managing clinical information. He or she must be adept at statistical analysis and be able to devise a medical management system that make use of the latest information technology. Along with this technical expertise, the medical director must be the champion that leads colleagues to the desired behavior changes. In order to have that kind of influence with clinicians, the chief medical officer must continue to be a clinician and practice his or her specialty to some extent. CMOs that do not provide some patient care will be seen as just another suit by the medical staff.

WHAT ARE THE MOST IMPORTANT INTERPERSONAL AND COMMUNICATION SKILLS?

The chief medical officer must learn to behave and think differently. If the physician executive functions as he was taught in clinical training, his peers will cut his throat. Various behavior changes are necessary. The CMO needs to learn and tech team building, teach colleagues to make decisions using consensus, have patience with the executive decision-making process, and become comfortable with the fact that in management it is not as easy to demonstrate success as it is in patient care.

The physician executive must not only take on a leadership development program, but is also responsible for the leadership development of physician peers. Finally, the chief medical officer must realize that, if there are 200 physicians on the medical staff, then he or she is dealing with 200 CEOs. If there are 500, then he or she is dealing with 500 CEOs. This is the only vice president in the system that has such as situation. If another vice president has responsibility for five or ten departments, then he or she only has to deal with five or ten individuals. The supervisors and workers in those departments do not expect to have direct access to the vice president of finance or operations or nursing.

Donald C. Bray

President and CEO of University Health Inc.,

A large integrated delivery system in Augusta, Georgia

WHAT ARE THE MOST IMPORTANT SKILLS FOR A CHIEF MEDICAL OFFICER?

There are four technical or business skills that are most important for a chief medical officer:

1. Medical management skills: Quality improvement, utilization management, development and implementation of clinical guidelines, and outcomes management. He or she needs to not only understand the processes and the data collection involved, but must be able to communicate the information to the clinicians, nursing staff, and administration in a way that all parties can understand and that effects the desired behavior changes.

2. An understanding of and experience in managed care and how the provider side could work with the payers and the recipients of care, both the employers and individuals.

3. A basic understanding of medical management information systems so that they could be used effectively in the areas already described.

4. A general knowledge of health care financing and hospital finances in particular.

WHAT ARE THE MOST IMPORTANT INTERPERSONAL AND COMMUNICATION SKILLS?

There are three communication skills that are the most important: conflict resolution, dealing with problem physicians, and the ability to run meetings efficiently. Physicians are conflict averse, so chief medical officers need to be able to confront physicians who are causing problems and tackle those kinds of problems head on. Most physicians hate committee meetings being able to not only run effective meetings but teach others how to do so is a valuable skill.

The personal traits that are most valuable in a physician executive are:

1. Being a team player. This trait does not come naturally for most physicians and needs to be learned.

2. Being a visionary. Successful CEOs must be visionaries and chief medical officers need to share that role.

3. Being a leader. It's hard to describe, but I know it when I see it.

4. Being able to think like a businessperson, but remaining true to his or her first calling as a physician.

CONCLUSION

These interviews with CEOs emphasize that business skills, such as an understanding of information technology, financial issues, quality management, and strategic planning, are essential for a chief medical officer to do his or her job. The communication skills and interpersonal traits enable him or her to interact with colleagues and coworkers to get the job done.

George E. Linney, Jr., MD, CPE, FACPE, is a consultant for Tyler & Company in Charlotte, North Carolina. He is also on the ACPE faculty and teaches career development. He can be reached by calling 704/364-0746 or via email at [e-mail].

David Kirschman is a Principal at the Physician Executive Management Center in Tampa, Florida. He can be reached by calling 813/963-1800 or via email at [e-mail].