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Each year for the past three years, the American College of Physician Executives has queried its membership to obtain a "catalog" of responses to management problems. Our goal has been to provide an array of problem-solving approaches that would add to the published experience of the medical management profession. In March of this year, we again asked members to provide brief accounts of major problems that they had faced in the preceding year, along with an assessment of the techniques that were used to resolve the problems. This article is a summary of some of the accounts that were received.

In the following compendium, the problems and their solutions are listed first under the type of organization (academic health center, government, group practice, hospital, managed care, or military) in which they were found. Under the organizational listing, the problems are listed by topic. For each entry, the name of the College member and his or her mailing address has been provided.

Every effort has been to make this listing a significant problem-solving resource for medical managers. Most problems can be solved most expeditiously if fresh insights are obtained from outside the immediate environment of the problem. The sharing represented by this listing should provide just such insights. Where a solution proves especially valuable to a reader, we hope that the adaptation of the solution will be shared with the College so that it can be disseminated more widely.

Academic Health Centers

Service Rivalries

A problem existed in interdepartmental programs in which two or more specialties shared a single subspecialty--for instance, hand surgery shared by orthopedics and plastic surgery, and gallbladder lithotripsy shared by gastroenterology, surgery, and radiology. Conflicting assertions of control over procedures existed. After agreement and understanding was reached among all the parties, a new departmental identity was created--for instance, hand service--in which the specialties shared responsibility.--Sam J. Romeo, MD, MBA, FACPE, Associate Dean for Clinical Affairs, Office of Clinical Affairs, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wis. 53226

Practice Development

Academic health center planned to place physicians from a salaried academic system into private practice groups. Several of the affected physicians had never worked in a private practice environment. The organization provided a number of "freebies" to the doctors, including four months' accounts receivable to cover initial operations, and contracted with the doctors for teaching assignments. It also provided business consultation for doctors not experienced in private practice management.--Larry D. Edwards, MD, FACPE, Vice President for Health Sciences, Oral Roberts University School of Medicine,

8181 South Lewis, Tulsa, Okla. 74137.

Government

Budgeting

City health department needed clear description of budgetary authority and responsibility for physician managers. Negotiations are under way with administrators and the CEO in order to develop a document that explicitly identifies the authority, responsibility, and accountability of physician managers in budgetary matters.--Richard A. Wright, MD, District Health Officer, Eastside Health Center, Department of Health and Hospitals, 2515 Albion, Denver, CO 80207.

Infant Mortality 

Health department, the only organization in the city with major responsibility for caring for the indigent, had to deal with an excessively high infant mortality rate. Full-time obstetrician-gynecologist was hired and successfully solicited funds for a "women's health center." Regrettably, major players were not consulted, including representatives of the indigent community, so there is a danger that the department will be selling an unwanted service. The failure to consult has also caused a schism within the department.-James J.Fullmer MD, Director of Primary Care, Duval County Public Health Unit Department of Health and Rehabilitative Services, State of Florida, 515 W 6th St., Jacksonville, Fla. 32206.

Group Practice

Marketing

Ambulatory care organization experienced ineffective marketing and a significant decline in census. A marketing manager was hired who proved to be effective. In retrospect, this position should have been filled earlier.-- Harry D. Stames, MD, Chief Executive Officer, Centra Care Medical Centers, Suite 375, 901 Lake Destiny Dr., Maitland, Fla. 32751.

Reorganization

Managers were dismissed following the partial failure of the business office and computer system. These events precipitated the resignations of higher levels of managers and administrators and a general decline in management morale. A reorganization process is currently under way.--James J McCusker MD, Medical Director/CEO, Woodland Clinic, 1207 Fairchild Court, Woodland, Calif- 9S695.

Physician Compensation

A confusing array of compensation methods were in place for physicians in the group. An outside consultant was hired to develop a standard system for the practice.--Michael E. Somand, MD, Medical Director, Fairlane, Henry Ford Medical Group, 19401 Hubbard Dr., Dearborn, Mich. 48126

Hospital

Practice Purchase

Hospital purchased several primary care practices and placed them under hospital oontrol, induding office management. Lack of knowledge of office practice management on part of hospital personnel caused near disaster. Before the situation was unrecoverable, management was shifted to out-of-hospital foundation under experienced office manager. All results not yet in, but attitude turnaround already evident.--Stanley M. Bugaieski, MD, Director Regional Services, Saint Francis Medical Center, 530 N.E. Glen Oak Ave., Peoria, Ill. 61637

Cost Containment 

CEO asked that medical staff cooperatively cut costs with no reduction in quality. At two- day educational session, input was solicited from medical staff. Medical staff is now establishirg methods to achieve the desired cuts.--Jeny L. Hammon, MD, FACPE, Senior Vice President Medical Affairs, Good Samaritan Hospital and Health Care, 2222 Philadelphia Dr., Dayton, Ohio 45406.

Emergency Care

Emergency department staff and patients complained about delays of 4-8 hours for lab tests, consultations, and observations. It was arranged for patients to be transferred to empty inpatient beds in the areas that were most appropriate to their diagnoses as "extended observation" patients. The patient is billed as an outpatient. If the stay exceeds 24 hours, the patient is converted to inpatient status.-Barbara LeTourneau, MD, Emergency Physicians, P-4., 1305 Pinehurst Minneapolis, Minn. 55116

Charity Care

Hospital desired to develop a charity care policy for the medical staff. First, an assessment was made of the policies of other institutions. Ideas were solicited from the medical staff through interviews and a survey. A draft policy was reviewed with medical staff leaders. Finally, the policy was approved by top management after review by executive staff.--Paul F. Bowlin, MD, Director of Medical Affairs, Fairview Southdale Hospital 6401 France Ave., South, Edina, Minn. 55435.

Confidentiality

Protection of patient information, particularly in phone calls from payers, was a prime concern. A policy of never giving information at the time of request was instituted. On a return call, it is validated that the caller is an insurer and that the caller works for the insurer. Only the original caller is called, and dates and times for all calls, along with the information released, are recorded in the patient's chart.--C W. Lowrey, MD, Medical Coordinator Rapides General Hospital 301 4th St, Box 30141, Alexandria, La. 71301.

Medical Records

A small but significant percentage of the medical staff did not comply with rules for medical record completion and documentation. Additionally, hospital employees were permissive with the medical staff with regard to records. The rules were tightened for employees, and offending physicians were called to make the new rules clear.--Francis X. McGinn, MD, FACPE, Administrato, r Medical Affairs, Hospital Center at Orange, 198 S. Essex Ave., Orange, N.J.07051.

To correct incomplete medical records, offending physicians are suspended for 30 days. If no compliance with rules in that time, the physician is dropped from the medical staff, with reappointment possible only by reapplication.--Robert J. Cangelosi, MD, Director of Medical Affairs, Hotel Dieu Hospital P. 0. Box 61262, New Orleans, La. 70161.

Service Departments

Members of service departments (anesthesiology, radiology, and pathology) were unresponsive to the needs of physicians who have primary responsibility for patients' care. Department chiefs were appointed by the hospital, but decisions on physician performance were determined by majority vote of department members. Exclusive contracts were negotiated with the service groups and disciplinary authority was given to the department chiefs. Members were not given recourse to hospital fair hearing provisions, so that a member leaving a group forfeits all medical staff privileges.--John A. Headrick MD, FACPE, Senior Vice President for Medical Affairs, Christian Hospital N.E.-N.W, 11155 Dunn Roach St. Louis, Mo. 63136

Quality Assurance

The hospital needed to implement a total quality management system on a low budget. The model selected integrates Joint Commission standards, technical (professional) competence, and customer requirements and is based on industrial models. The difficult job of integrating physicians into the model is currently under way.-- Clara Jean Ersoz, MD, rice President Medical Affairs, St. Clair Hospital, 1000 Bower Hill Road,Pittsburgh, Pa. 15243.

Managed Care

Physician Relations

Physicians in IPA-model HMO have acted as adversaries to plan management. Medical director is meeting individually with physicians to improve communication, clarify common goals, and enlist support. Result has been positive to date, but long-term results are unclear.--Hal A. White, MD, MPH, FACPE, Medical Director, Medical Value Plan, P. 0. Box 2147, 405 Madison Ave., Toledo, Ohio, 43603.

Cost Control

Large sums of money were being lost at most HMO sites. Employees were enlisted in effort to develop list of problems causing losses. Task forces were formed to address major categories of problems identified by employees. The analysis and recommendations of the task forces were surveyed by a management steering committee, and breakeven for the units is now imminent.--Lawrence P. Tremonti, MD, FACPE, Vice President Medical Affairs, Health Options-Blue Cross/Blue Shield, 532 Riverside Ave., Jacksonville, Fla. 32207.

Financial losses were mounting, and the HMO board wanted immediate aaion from management. The short-term answer was to reduce senior and middle management staff. The situation was turned around, but not without some scars for the organization.--Henry S. Berman, MD, FACPE, President and Chief Execufive 0fficer, Group Health Northwest, W. 1500-4th Ave., P.O Box 204, Spokane, Wash. 99210

Financial Management

Organization found itself in violation of working capital requirements of bank ban, which raised principal payments to an unacceptable level. An arrangement was negotiated with another bank at considerably better rates and for a sigfnificant line of credit.--Julius V. Combs, MD, Chairman and Chief Executive Office, r United American Healthcare Corp., 7650 Second Ave., Detroit Mich. 48202.

Merger

Group practice HMO realized that future growth would be hindered because of undercapitalization. Steps have been taken to identify merger partner, and discussions have taken place on possible conditions of merger. No specific action has been taken to date.--Paul R. Lenz, MD,FACPE, Vice President and Medical Director, Rutgers Community Health Center, 57 U.S. Highway 1, New Brunswick,, NJ. 08901

Incentive Plan

Organization desired to develop incentive plan for physicians that emphasized patient satisfaction and quality of care rather than cost containment. Measurements were developed for scoring patient satisfaction from telephone interviews, for quality of care evaluation for inhospital and ambulatory care, and for costeffectiveness.--Jerome S. Beloff, MD, Vice President and Corporate Medical Director, A V-MED Health Plan, Suite 325, 9400 S. Dadeland Blvd.,Miami, Fla. 33156.

Military

Continuity of Care

Consultations were received from a wide variety of practitioners from both inside and outside the organization, and there was no tracking system to ensure that patient needs were met and documented. A clerical position was created, along with a logging system so that each consultation is logged, pursued through specialty appointment, and then filed and returned to the primary physician.-- COL Herbert E. Segal,MC 605 Baltzell Ave., Foil Benning, Ga. 31905.

Pharmacy

Pharmacy system fills more than 2,000 prescriptions per day and consists of seven locations scattered over a three- state area. A computerized system was developed, procured, and implemented that automatically fills prescriptions, performs quality assurance functions, and orders pharmaceuticals for the system.--COL Robely B. McLean, MC, FACPE, United States Army, 8205 Hensley Court, Alexandria, Va. 22308.

Physician Recruitment

Military hospitals had shortages of physicians in critical specialties and were unable or unauthorized to recruit to fill positions. Decision was made to contract for the services. Results have been mixed. Process is very difficult and time-consuming, and details must be spelled out to avoid overcharging or poor quality care. Services could not have been acquired otherwise, however.- -William Robert Rowley, MD, Assistant Chief of Staff, Plans and Operations, Naval Medical Command, Southwest Region; San Diego, Calif- 921347000.