Management competencies required on ambulatory care settings. (Physician Executive Management Competencies).

THE INTEGRATION OF FINANCING AND HEALTH services delivery under the explosive growth of managed care has become a dominant characteristic of American health care. (1, 2, 3 Massive, market-based reform has rapidly transformed the traditional, provider-driven, loosely associated system of solo practitioners, small medical groups, and free-standing community hospitals (4) into a payer-driven, "corporatized" world of hospital systems and large group practices. (5) These systems are being dominated increasingly by multi-state insurance companies and large, investor-owned managed care companies. (6, 7)

Frustrated by failures to control enormous escalation in health care costs under the "perverse" incentives of indemnity-based fee-for-service, corporate America and our political leaders have embraced a "common wisdom" that managed care in a competitive marketplace will effectively control the problem of rising costs, while maintaining acceptable levels of quality and access.

This fiercely price competitive market for managed care appears to have slowed growth in health insurance premiums recently. (8)

However, there is a growing recognition that the over-application of the business model, reflected in the emerging organizational forms of managed care companies, may have serious negative implications for quality and access. This business model is characterized by: A focus on managing risk and costs, rather than on managing care; (9) a commoditization of medical services; (10) an emphasis on the Medical Loss Ratio (11) and shareholder value," rather than the quality or effectiveness of services provided: (12) and an increasingly intrusive micromanagement of physicians to assure conformity to corporate goals of pricing and profit. (13, 14)

As health care organizations continue to consolidate into integrated medical groups, large hospital systems, and diversified insurance plans, they are facing an erosion of public confidence. There is an increasingly vocal "consumer backlash" against the incentives inherent in managed care to under-treat patients and threats to physicians as autonomous clinical decision-makers and patient advocates. (1, 5, 14, 15, 16, 17)

There appears to be an emerging consensus that, to retain their credibility with the society that empowers them, health care organizations must change their focus on price competition to a demonstrable emphasis on cost-effective quality, or "value." (2, 18, 19) To cope successfully with growing public and political disenchantment with the downside risks of "brokered" care, (13) integrated delivery systems must move beyond their current array of voluntary alliances and contractual arrangements, based on a continuation of traditional, arms-length relationships with their medical staff, They must develop effective clinical leadership structures that truly integrate their core clinical technologies and processes, whose essence remains focused at the individual patient-clinician interaction, (20) along with corporate fiscal and other performance goals. (4, 21, 22)

To attain the clinical and economic integration necessary to effectively balance cost and quality and remain competitive in an increasingly demanding political, social, and economic environment, health care organizations are turning increasingly to physician executives as fully integrated members of their management teams to engage in "medical management." (23, 24) Developing the organizational structures, roles, and processes capable of effectively managing complex clinical work environments and ensuring necessary professional influence over clinical decision-making will represent a radical departure from the American health system we know. Incorporating physician executives as key managers of clinical operations will require a major organizational restructuring and a thorough reevaluation of the roles, expectations, and competencies required of physician and nonphysician health care executives. (21, 25)

Literature review

American health services delivery organizations have used dual lines of authority to recognize and institutionalize roles and relationships between administrator managers and physicians, under the uniquely American concept of the arms-length relationship between the hospital and its formally organized voluntary medical staff. (26,27) Clear distinctions between non-clinician managers and physicians, and the premise that organizational management provides support services but must not interfere with the practice of medicine, have been emulated in non-hospital institutional settings. (27, 28, 29)

Indeed, health services management has evolved as a distinct specialty in an environment in which managers had little effective control over the core production processes of their organizations. (24,28,30,31) Conflict with the largely autonomous medical staff has been "contained" through a carefully choreographed set of constraints and prerogatives embodied in the medical staff bylaws. The role of the physician executive, whether on the governing board or as chief of the medical staff, has been largely representational, as a "guest" or "ambassador" in the "House of Management." (32) Although enormously costly, this approach has preserved the sanctity of the physician-patient relationship, avoided cost-quality tradeoffs under fee-for-service indemnity insurance, and produced a system that had strong credibility with the society it served.

As managed care organizational and contractual arrangements increasingly limit professional influence over clinical working environments and decision-making, there is growing public concern over the obvious conflict between the role of the physician as patient advocate and the dictates of corporate fiscal and economic requirements. In this "economic era" of continuing political and economic demands for constraints on costs, in which price competition implies losers as well as winners in the marketplace, hospital systems and ambulatory organizations alike must manage complex issues involving difficult tradeoffs between cost and quality. (4)

Health care organizations across the spectrum of size and complexity will require physician-managers who can effectively integrate clinical knowledge and management disciplines to improve practice efficiency and balance organizational and clinical dictates. (21, 25, 31) The competencies and skills implied by these emerging imperatives for physician leaders appear to be profoundly different from the traditional representational, advisory roles that have characterized medical staff leadership. (33) The competencies needed may require a major reorientation of formal and continuing education programs aimed at both clinician and non-clinician health services managers.

The literature, for some time, has reflected considerable interest in forecasting the future of health services delivery and in estimating executive skills that will be needed to cope successfully with organizational demands. (34, 35) Despite the increasing movement from inpatient to ambulatory settings, the majority of studies have addressed non-clinician health care executives in hospital settings. (35, 36, 37)

Recent theoretical assessments of the emerging need for physician managers to integrate and coordinate clinical and managerial processes have also tended to focus on the hospital, health system, or, more recently, the managed care plan level. (33, 38, 39, 40) General themes emphasize the concern with a growing lack of fit between traditional health care organizational structures, with their dual lines of authority and the somewhat adversarial relations that have prevailed between managers and physicians, and the environment of managed care and market competition. (23, 41, 42)

This lack of structural-environmental fit may be inferred from the difficulties that health care organizations are encountering in trying to integrate physicians, through practice acquisitions (27) or physician-hospital organizations/management service organization initiatives, (43) while retaining the traditionally marginalized roles of physicians as advisors, representatives, or liaisons to organizational management structures.

As integrated delivery systems appear to be disintegrating into their constituent parts, (42) consensus is emerging that to survive the conflicts inherent in competitive managed care, health care organizations must evolve from "virtually" integrated systems to "organized delivery systems" (4) that rely on physician managers to enhance management control over their core technologies and processes. (23, 31, 32) In ways similar to professional firms in the engineering, architectural, or accounting industries, health care organizations must seek to "rationalize" their central knowledge and expertise through physician executives, who uniquely combine management skills with technical expertise and are focused on understanding, interpreting, controlling, and improving the clinical processes that comprise their core technology. (23, 32)

In growing numbers, physicians are serving in clinical-management roles in a variety of medical group, hospital, health system, and corporate settings throughout the industry. (23, 33) Increased direct physician involvement in governance and financial integration leads to improved organizational performance, in terms of reduced resource utilization, lower costs, and increased operating margins. (44)

There also appears to be a relative scarcity of physicians with the requisite education, skills, and competencies needed to successfully assume the expanded clinical leader and manager roles being demanded. (40, 42) The professional model of medical education and training neither covers nor equips physicians for managing complex organizations. (31, 39, 45) The opportunity costs to physicians of learning management skills, much less performing them, have dissuaded most from preparing themselves to assume the emerging clinical management roles. (31)

Physician executive roles

There is a steadily evolving expansion of physician executive roles as managers of clinical operations within health care organizations. A mail survey of physician managers in a variety of group practice and other ambulatory settings found high levels of physician involvement in managing medical personnel and quality assurance, but low levels of involvement in finance. (46) Similarly, a study of physicians in hospital management positions found that physician executives were most frequently involved in tasks dealing with policy management, in such areas as accreditation, credentialing, and clinical performance, and least likely to be involved in financial management. (47)

Kindig and Lastiri-Quiros (48) reported that tasks most frequently encountered by physician executives were managing internal clinical operations, other physicians, and quality. These authors focused on the growing importance of boundary-spanning roles for physician executives between general management responsibilities and managing clinical activities and professionals.

The expansion of these boundary-spanning roles reflects the increased physician involvement in key management decision-making processes and the need to balance cost and quality issues. (33) The value of physician executive contributions to health care organization performance and effectiveness was rated higher by non-physician executive colleagues than by physician executives, in both hospital and medical group settings. Both groups ranked evaluating physician practice efficiency as most important, followed by improving quality assurance; maintaining effective medical staff relations; defining goals, priorities and direction; and improving efficiency of day-today operations. (33)

The literature suggests that rather than replacing the traditional administrative support roles of health care executives, the emergence of specialized physician manager roles is responding to an urgent need by health care organizations for effective management of their clinical processes, as they continue to integrate venically. (31) Expectations are that as health care organizations evolve into "organized delivery systems," they will require increased rationing and integrating of clinical and nonclinical management functions. (31) Since the point has been made that it is easier for physicians to learn management than for administrators to learn medicine, (31) it seems reasonable to expect that there will be an expansion and clarification of physician executive roles, functions, and expectations, as health care organizations search for a better structural fit with their volatile and competitive environments.

Physician executive competencies

There is strong consensus that the competencies required of physician executives in their expanded roles will differ substantially from the relatively informal and highly collegial roles of the past. (32,39) Organizational demands for managing clinical processes and resource flows will not support establishing physician leader positions merely as another "professional prerogative." Indeed, physician leaders will be required to demonstrate the same levels of managerial expertise and performance as their non-clinician colleagues. (23) As part of a differentiated management team, physician executives will be expected to bring important specialized expertise to bear on organizational governance systems, as do colleagues in finance or marketing. (46,49)

Although they will be expected to have fundamental skills in finance, accounting, and other management disciplines, physician executives will provide their essential advantage based on expertise in "medical management as a clinical science." (46,49) Specific competencies, in areas such as medical informatics, medical decision-theory, and the social psychology of medical practice, will enable physician executives to provide value-added management. This will be grounded in their experiential understanding of the medical care process and the culture and values of the physician-patient relationship and their insight into the complexities involved in cost-quality tradeoffs, particularly at the individual patient level. (49)

We have known for some time that physician executives report strong needs for self-improvement in communication, management decision-making, teambuilding, and conflict resolution. (40) Physician executives must overcome long-standing differences between managers and professionals in focus, perspective, time horizon, and decision processes if they are to successfully contribute to organizational issues, such as patient care standards, cost containment, resource utilization, and physician evaluation and management. (43)

As health care shifts from its traditional focus on service delivery to managing the thorny issues of cost, quality, access, and social equity, physician executives will be expected to demonstrate competency in "the application of systematic strategies for managing the clinical processes of care." (21) To respond successfully to expanded physician executive competency needs, graduate and continuing education programs will need to expand their curricula to incorporate "clinical-fiscal performance methodologies." (21)

Physician executives will be called on to contribute their specialized expertise in clinical-fiscal management, in areas such as technology assessment and the appropriateness of care; physician recruitment, selection, credentialing, and performance evaluation; and the increasingly complex issues involved in the cost-quality tradeoffs related to defining "value" in health care, They will also be expected to be well-versed in areas such as clinical process management and evaluation; benchmarking; outcomes assessment; quality evaluation and control; medical informatics; and productivity measurement and input pricing. (21)

What are the most important competencies?

A study was conducted to identify the most important competencies physician executives, in medical groups and other ambulatory settings, will need to have in the next five years. The research also explored the specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies.

The study design consisted of two rounds of the Delphi technique for executive decision-making, conducted among physicians of the American College of Medical Practice Executives (ACMPE). These experienced, ambulatory care physicians were uniquely positioned, by virtue of their roles in clinical and administrative operations, to provide practitioner-based estimates of the management competencies and related skills, knowledge, and abilities (SKA) needed to cope successfully with the demands they were likely to face into the next century.

Data were collected via two Delphi rounds in the form of mailed questionnaires that were separated by an expert panel for content analysis. The Delphi technique, developed by the RAND Corporation (50,51,52,53) has been used extensively in a variety of health care settings to predict future trends and establish priorities. (34,35,37,54,55,56,57,58,59)

During the first Delphi round, the ACMPE physicians were asked to identify the top five competencies that medical practice physicians will need to know in the next five years. Respondents were also asked to describe the specific management skills, knowledge, and abilities (SKAs) medical practice physicians will need to achieve the referent competency. The response format was open-ended to "capture" the job knowledge and language of the respondents. Additional insight was gauged for each competency by asking what particular SKA supported the chosen competency.

A roster of unique competencies and the number of times physicians listed each competency was supplied to the expert panel. The panel grouped the competencies into 13 "management domains," Figure 1 represents these management domains in descending number of competencies grouped per domain. Specifically, these domains are:

1. Managing Health Care Resources to Create Quality and Value (MR)

2. Fundamentals of Business and Finance (BF)

3. Leadership and Management Competencies (LM)

4. Development of Vision and Strategic Planning for Health Care Delivery Systems (VSP)

5. Communication/Interpersonal Skills (CIS)

6. Human Resources and Performance Management (HR)

7. Negotiating and Contracting (NC)

8. Change Management (CM)

9. Governance and Policy Development (GPD)

10. Defining, Servicing, and Growing Your Market (Mkt)

11. Applying Electronic Communications to Medical Practice (EC)

12. Ethics: Medical, Business, Legal (E)

13. Maintaining Your Competency for the Future (MC)

During the second round of decision-making, ACMPE physicians were asked to review the feedback and to assign relative importance ratings for the SKAs within each management domain on a 7-point relative bipolar adjective rating scale. The respondents' demographics were gathered as well. Ninety-three percent of the respondents were male, with an average age of 50 years. More than 29 percent had a master's degree, evenly split between health care-related and non-health care-related fields. About 5 percent held a doctorate degree. On the average, the executives had more than 23 years of experience in a health care setting and nearly 22 years as providers. Further, respondents reported an average of almost 10 years of management experience and, in their various settings and organizations, reported supervising from a few to several hundred employees.

Identifying the competencies.

As reflected in Figure 1, two management domains, "Managing Health Care Resources to Create Quality and Value" and "Fundamentals of Business and Finance," had the same number of competencies. However, there were similar numbers of competencies in the next three Domains--"Leadership and Management Competencies," "Development of Vision and Strategic Planning for Health Care Delivery Systems," and "Communication and Interpersonal Skills"

This close grouping of domains suggests that the physicians recognize the need for proficiency in numerous competencies. In addition, these competencies may not be learned through similar venues, but may require a substantial broadening of educational preparation for physician executives. For example, "Managing Health Care Resources to Create Quality and Value" and "Fundamentals of Business and Finance" are probably not compatible in a traditional continuing education "short course." Physicians may require substantial, formalized education and training to achieve needed competencies in "clinical-fiscal performance methodologies."

"Communication and Interpersonal Skills" had the largest total of competencies, suggesting that these qualitative skills are more clearly recognized, and discretely defined, by physicians as a critical competency. An interesting finding is the relatively small number of competencies associated with the "Ethics: Medical, Business, Legal." and "Maintaining Your Competency for the Future" domains. These low numbers may not reflect the broad number of competencies required, but may, in fact, confirm that these domains have just a few fundamental competencies needed for successful management by physicians.

The SKAs rated most important

The highest-rated SKA, "ability to build and maintain trust," is in the "Leadership and Management Competency" domain. In fact, the top four SKAs, and six of the top 10 SKAs identified as most important, are associated with this domain. These SKAs are extremely important, regardless of the need for competency in other management domains. In fact, with the exception of three SKAs ("Know and apply practice valuation techniques," "Knowledge of capital investment strategies," "Focus on outcome, not process, as measure of improvement"), none of the SKAS are associated with the domains discussed previously.

Achieving and maintaining the lowest-rated SKAs is not as high a priority to these physicians. In other words, medical practice physicians may wish to consider initially concentrating on seeking and maintaining proficiency in business, finance, and quality-oriented competencies, with their related SKAs. To maintain this broad range of competency suggests that physicians should consider training and education in both formal (e.g., continuing medical education hours) and non-formal educational venues, including professional and personal experiences, performance reviews, mentors, and role models. Furthermore, it is recognized that perceived competency priorities may evolve over a physician's career in ambulatory practice.

The implications of these findings on physicians' education and training programs may be substantial. Certainly, formal education programs should address communication and interpersonal skills, managing health care resources, and the fundamentals of business and finance. Competencies associated with "creation of quality and value" support the suggestions of theoretical discussions that renewed emphasis must be placed on course content that provides physician executives with skills in measuring and managing the quality and effectiveness of clinical activities, from epidemiological as well as fiscal perspectives. Similarly, programs offered by professional associations and consultants should ensure currency in these competencies. This education and training may be supplemented through such techniques as using mentors and role models.

Conclusion

This study identified the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years, as well as the specific job skills, knowledge and abilities (SKA) needed to acquire these competencies. Medical practice physicians require a large array of competencies involving managing clinical quality, as well as business and finance issues. In addition, irrespective of competency 'domain," there are several SKAs that are extremely important and involve issues of credibility, trust, honesty, and interpersonal communications. As physician executive roles continue to expand to managing other physician clinical activities, these SKAs will assume even greater importance. On the other hand, less significance appears to be placed on physicians possessing such SKAs as the ability to know practice valuation techniques and to evaluate software.

These findings should assist physicians in their performance, training, education, and development. This study suggests that medical practice physicians are required to maintain clinically-oriented competencies while learning business-oriented and interpersonal competencies. Possessing these competencies with their supporting SKAs will assist the medical practice physician to be successful for the next five years.

FIGURE 1

COMPETENCIES GROUPED PER MANAGEMENT DOMAIN


MR   41
BF   61
LM   58
VSP  58
CIS  54
HR   43
NC   39
CM   33
GPO  25
Mkt  22
EC   10
E     7
MC    5

Paul P. Brooke, Jr., PhD, FACHE, Ronald P. Hudak, JD, PhD, FACHE, Kenn
Finstuen, PhD, & James Trounson

Note: Table made from bar graph

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Paul P. Brooke, Jr., PhD, FACHE, is Professor and Dean of the School of Allied Health at Texas Tech University Health Sciences Center in Lubbock, Texas. He can be reached by calling 806/743-3223..

Ronald P. Hudak, JD, PhD, FACHE, is an Associate Professor of Health Services Administration at Uniformed Services University of the Health Sciences in Bethesda, Maryland. He can be reached by calling 301/295-3830.

Kenn Finstuen, PhD, is a Professor at the U.S. Army-Baylor University Graduate Program in Health Care Administration, Academy of Health Sciences, in Fort Sam Houston, Texas. He can be reached by calling 210/221-6730.

James Trounson is President of Medical Management, Inc. in Boise, Idaho. He can be reached by calling 208/338-1122.

The opinions expressed herein are strictly those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U S. Government.