Outcome management issue tops conference agenda.

The development of a national system for judging the quality of health care services on the basis of outcomes was the subject of the inaugural Baxter Foundation Lectureship at this year's National Conference on Health Care Leadership and Management, held May 1-3 in Washington, D.C. Paul Ellwood, MD, expanded on concepts that he introduced in the Shattuck Lecture of the Massachusetts Medical Society last year.1 Other speakers at the Conference discussed the development of an anticipatory approach to technological innovation and the attributes that lead to success in physician executives.

In recent years, the delivery of health care has been dominated by considerations of costs. When issues of quality have been raised, they have been raised in terms of the cost/ quality equation. Paul Ellwood, MD, Chairman of the Board of InterStudy, Excelsior, Minn., believes that this intense concentration on the production process has caused the health care field to lose sight of its product, health care improvement.

"Most of the health care in this country is provided by organizations. Organizations are now in the practice of medicine," Dr. Ellwood says. "Our ability to manage these organizations has by no means kept pace with advances in medical care or, for that matter, lived up to the expectations of the public. In spite of spending extraordinary amounts of money on health care, we have a public that is disappointed, doctors who are angry, politicians who don't know where the next dollar is coming from, and payers who feel the same."

Dr. Ellwood believes that organizations delivering health care services should be headed by physicians. But, he says, "physicians will not be granted the opportunity to hold truly executive positions until health care organizations can become publicly accountable for the health care they produce." Physician executives should convince both the organizations and the public that health care organizations deliver health, he says. Even though physicians are now in management positions in a wide variety of provider settings, Dr. Ellwood says, they are mostly responsible for "money, personnel, technology acquisition, and ambience. They are only indirectly responsible for the health and the quality of life that their organizations produce for patients."

Dr. Ellwood says that a good idea of where health care organizations place their emphasis can be found in their annual reports. He says that his assessment of these documents is that they concentrate exclusively on their buildings and technology; on what "wonderful places to work they are"; on production statistics, such as annual changes in laboratory tests performed, and on financial detail& None of them list their impact on patients' health. They offer lots of claims, but no tangible evidence."

Dr. Ellwood says that recent efforts to reform the health care system through restructuring have been undermined by the public's "inability to make a distinction between good care and bad care and by its continuing assumption that more medical care is better medical care." He says that the efforts are also undermined by the system's inability to identify those interventions that are most likely to be effective. "No business can succeed with ill-informed and very demanding customers and with such a poor understanding of its production function,' Dr. Ellwood says. "That's our dilemma. That's a nice way of saying that we don't know what we're doing."

Dr. Ellwood says that data must be collected from patients on their preintervention and postintervention quality of fife. Data would also be collected from providers to determine what has been done for the patients and at what cost. The physician executive's job, he says, is to sort through those data and help the organization improve the quality of the care it provides. "You are the people who understand how your organizations affect peoples' health. We have to abandon the way we have dealt with quality in terms of search and destroy missions against outliers. It is the average provider that has to be improved to improve the system," he says.

Dr. Ellwood says that medical management must be viewed as a clinical science. "Physician executives should stake out for themselves the unique core of scientific knowledge on how organizations make a difference in the provision of health." For that, he says, physician executives will need to begin to develop a management information system that works for the patient. "Health care organizations should be treated like patients," he says. "They should be listened to, attended to, examined, observed, treated with dignity, and managed decisively and effectively." Physician executives, he says, because of their clinical involvement, are uniquely positioned to ensure good organizational results.

Beware of the Wolves 

The need for executive leadership "is as strong for the medical management profession as it has ever been," according to Morgan McCall, PhD, Senior Research Scientist and Visiting Professor, Center for Effective Organizations, Graduate School of Business Administration, University of Southern California, Los Angeles. And, he said, the need is growing stronger. "Unless you find it and generate it, somebody else is going to take that leadership from you. I think it is already happening. The wolves are at the door." Dr. McCall says that the public, business, and government are aH expressing dissatisfaction with the health care delivery system and can take the leadership to change the system.

Dr. McCall insists that leadership is a profession. There are specific things that leaders must know and be able to do, he says. And there are six qualities that the leader needs. He encouraged his audience to look for the qualities in themselves and to encourage their development in others. Though it is commonly believed that leaders are born, not made, he says that leaders work very hard at building these qualities. Leaders:

*Are able to set and implement agendas. The leader has a vision and makes it happen.

* Handle interpersonal relationships effectively. "You can't fire everybody." The leader works to get the best out of his people.

* Have a unique set of values. It isn't necessary to relinquish your values, only to add those that affect how you relate to others.

* Have a different temperament. Leadership is stressful, but "they love it." They are comfortable with ambiguity.

* Have self-awareness. They understand their limitations and weaknesses and strive to overcome them. They are not afraid of mistakes and establish an environment in which they and others can make and learn from their errors.

* Are able to learn from experience. Dr. McCall says that if you don't learn and grow through experience, the result is leadership by accident. The recent history of U.S. industry shows the sad result of that kind of leadership, he says. He says that courses in management and leadership are important, but they are no substitute for experience.

If It Works, it's Obsolete

"Change has changed," says Daniel Burrus, President and Founder of Burrus Research Associates. "Things are moving much more quickly," he says, "because of computerization and economic globalization." While we have gotten used to dealing with cyclical change, he says, we have not yet adapted to the structural changes that are becoming commonplace. He says that permanent @ are coming from science and technology, and they "can be predicted."

Mr. Burrus says that the "deck of cards that we all must play with will be getting some new cards in the future, and we all have to learn to play with them." He predicts that tremendous changes will come from several technological sources. For instance, it is already possible to create full-color, three dimensional images with lasers. "An entire army could be projected on a field. The implications," says, are immense. He says that similar massive technological innovations can be expected in optical storage systems, genetics, bioelectricity, fiber optics, digital electronics, and a host of other areas.

The 1990s, he says, will be the communications age, replacing the information age. Leadership," he says, "is having a plan and rallying your people behind it. To be successful in that, you have to be able to communicate."

*Ellwood, P. "Shattuck Lecture-Outcomes Management: A Technology of Patient Experience." New England Journal of Medicine 318(23):1549-56, June 9,1988.

T H E A U T H O R Wesley Curry is Editorial Director, American College of Physician Executives.