Physician-centered management guidelines. (Beyond Managed Care).

As HEALTH CARE

organizations struggle to survive in the current Darwinian environment. they have often ignored the pivotal role of their internal human resources in attaining success. They have not recognized the importance of acquiring, cultivating, and preserving their intellectual capital nor have they sufficiently invested in their most valued employees. Unlike these organizations, the "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between employee satisfaction and productivity. service quality, and, ultimately, organizational success. Health care organizations that embrace these principles and develop physician- responsive and centered delivery systems will acquire a sustainable competitive advantage in today's health care marketplace.

The physician-patient relationship is unique and unlike most economic commodities. It is characterized by a complex, highly personal, technical, and labor-intensive role, predicated on continuity, and with a low tolerance for error. These attributes make it unlikely that physicians will become interchangeable components in a mechanistic model of medical care. When surveyed, most patients equate "quality of care" with choice of physician and even HEDIS. hidden among its 71 performance set measures, rates "physician turnover" as a performance criterion. The classic command and control hierarchical model of management is incongruent with a physician workforce and maladapted for today's rapidly changing, market driven. and customer responsive environment.

Although health care institutions extol the virtues of evidenced-based guidelines for care improvement, they have failed to inform their managerial control systems with the modern behavioral and managerial sciences. Confronted with a workforce that is demoralized and alienated, they cannot afford to respond with management approaches that are reactive, derivative, and anachronistic, If health care organizations hope to recruit and retain the quality workforce upon which its core competency depends, they must develop a vision, strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care.

What follows is a conceptual framework for effective physician management, a "critical pathway," that will enable heath care organizations to add their name to the list of "most admired."

1. Purpose

It is imperative that leaders of organizations articulate and communicate a compelling and coherent mission. These shared values represent an organizing principle, unifying vision, and overreaching direction for planning, structure, and decision-making. Historically, physician groups have coalesced around an originating physician founder. They were homogeneous with common norms, objectives, and culture.

As health care consolidated into networks of hospital or plan owned medical groups, physicians have been transformed into acquisitions on a corporate P+L statement. They are now loosely aligned, with poorly defined goals and an ambiguous raison-d'etre. In today's turbulent times of rapid and profound change, it is the clarity of the "future state" that will support physicians and physician groups through difficult transitions and motivate them to make the fundamental changes critical for success.

The managerial maxim, "if you don't know where you are going, any road will get you there," is particularly cogent. An organization's mission must be more than a list of platitudes in a lucite wall frame. It should be a living document, a set of well thought out goals and shared values, which can guide strategic planning, inform decision-making, align constituents, provide organizational cohesiveness, and serve as a reference with which to measure group success. Once established, this vision must be reiterated and reinforced at every opportunity, communicated so as to provide a sense of urgency for change, and embraced and supported at the highest organizational level.

2. Plan

The goals of an organization drive its strategic plan, which serves to translate purpose into practice. The strategic plan represents a road map that provides direction, guides resource allocation, and determines the method and means to implement organizational objectives. Traditionally. health care organizations have operated on the premise, "if they build it, they will come." In the new era of accountability, they must now demonstrate added "value" and constantly compete to not only meet, but exceed the established benchmarks.

It is not merely sufficient to match one's competition pin for pin on a marketing map. to replicate their vertically integrated networks, or focus on what is perceived as lucrative narrow market segments. Such "group think" precludes the innovative breakthrough strategy which, in a complex and dynamic environment, is a prerequisite for sustained market success. Strategic planning must be rooted in a clear understanding of the desired future state, organizational competencies, the values of all constituents, the operational performance gaps, and prevailing realities. The recent accelerating decline in health plan profits and collapse of major providers illustrates the danger of strategies that are confused, imitative, and unrelated to coherent long-term objectives.

3. Process

Organizational design and structure must support the vision and strategic plan. Historically health care systems have been characterized by fragmentation, a lack of coordination, redundancy and inefficiency, and poor communication, Initiatives and systems were conceived and implemented without a clear understanding of the providers and process of care. The market now demands interdependence, collaboration, and continuous quality improvement. It will not tolerate the entropy and inertia of large bureaucratic institutions. To meet this challenge, health care systems must become a physician directed partnership between physician, payer, plan, and patient. They must be redesigned, utilizing the tools of quality management, so that systems support the physician role and facilitate the goals of efficient and effective care delivery.

4. Participation

In the past, physician practice was characterized by autonomy, control, independent decision-making, and an action orientation. Physicians now find themselves subordinated to managed care and hospital dominated organizations that demand conformity to external standards and mandates. They must practice within narrow constraints that often compromise their financial and clinical prerogatives. Until recently, physicians have not asserted their collective influence. There are all too few physicians executives in command of major health care organizations and physicians have been unable to or prohibited from forming physician-sponsored organizations.

Meaningful physician participation and empowerment is a prerequisite for the ownership" and "accountability" that is essential to organizational success. Physicians must be represented at the highest level of governance and provided with a sense of control over the delivery of patient care and their professional destiny. Endowed with an Intimate knowledge of care delivery, trusted by patients, and still respected by payers, they are in the best position to improve organizational performance. Physicians themselves must recognize that they are at the locus of power and abandon adversarial, uncooperative, and "passive aggressive" responses to change. They can either relinquish control and sell their professionalism to large for-profits or demand and accept the control and accountability that will permit the creation of care systems that serve their interests and the interests of patients.

5. People

Currently, "quality" is assessed at the health plan level, which reflects overlapping networks of virtually similar panels of physicians. True quality differentiation, however, occurs at the practice level. As groups consolidate into more exclusive provider networks and compete more on quality than price, it will be those networks that attract the highest quality physicians that will achieve market dominance. The 'best and brightest" will align with organizations that respect and reward physicians who deliver efficient and superior clinical care. The Thigh performance" organizations in medicine will be those that invest in training and provide opportunities for career enhancement.

6. Public

An essential attribute of a winning organization is open communication and the capacity for dialogue. All of us have practiced in circumstances where most nonclinical conversations occurred behind closed doors. We have experienced the demoralizing innuendoes and debilitating organizational politics this environment cultivates. Successful organizations explicitly. consistently, and constantly discuss objectives, strategy. And problems. They proactively confront the inevitable resistance that accompanies transitions and transformations.

Communication is the basis of the trust and confidence that engenders teamwork, collaboration, commitment, accountability, and the change process. Openness minimizes the all too common laments of "work not appreciated" and complaints that decisions are unfair." Communication is particularly critical in a rapidly changing and hostile environment when the culture, roles, structure, and power relationships of the organization are being challenged and individuals are uncertain and fearful about their future.

7. Principled

Long-term relationships, either individual or organizational, cannot be sustained without fairness and equity. The perception and reality that all individuals are treated with respect, efforts rewarded fairly, and commitments honored is integral to the success and stability of organizations. Physicians will rarely challenge decisions that they perceive as fair, no matter who they favor and much of the practice of medicine is based on a trusting self-sacrificing professionalism. Distrust and suspiciousness must not be permitted to undermine the collegial practice and open relationships that represent core attributes of patient care.

8. Performance

"We are what we measure." An organization's appraisal and incentive system must be aligned with its strategic goals and designed to foster its mission. Incentives must reinforce expectations and, preferably, be positive rather than punitive. These reward systems are the primary determinant of behavior. Many of us have experienced the schizophrenia of productivity-based variable compensation systems, despite the fact a practice is heavily capitated. Incentives should be congruent with group values and attainable. Although they need to reward individual initiative and performance, they must also ensure that most efforts are directed towards accomplishing the overall organizational goals.

9. Patient

Successful organizations must innovate and experiment. They should encourage risk taking and tolerate the failure that may follow. Success cannot be measured by quarterly earnings reports, but must be nurtured and allowed to germinate and flower. Medicine is being reinvented. There have been profound changes in culture, a radical redefinition of roles, and shifts in the power of entrenched bureaucracies. Consequently, fundamental change will require years of effort and commitment. If change is too rapid it will most likely be superficial and evanescent.

For every organization, there is a "dashboard" of performance indicators that are used to measure success. Most successful organizations include "employee satisfaction" in these performance measures and recognize the value of incorporating these employees in the change process. In health care, too few have embraced this proposition. This ignorance may be partly responsible for the widespread disenchantment and demoralization of physicians, the decline in patient satisfaction, and, ultimately, the inability of health care organizations to prosper under new financing mechanisms and relationships.

Conclusion

The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost effectiveness. Positioned at the interface of care delivery, physicians are the appropriate architects of organizational redesign and, as the primary patient advocate, a "physician-centered" delivery system will likely be a "patient-centered" one. This call for physician centrality is not to argue for the restoration of the self Interested fraternity model of practice of the 1980s, but to place the experts of care in their rightful role and to appropriately limit the influence of non-physician entities on care delivery.

Physicians may, ultimately, be transformed into interchangeable "commodities." If so, they may marshal their collective influence and engage in the adversarial and positional bargaining that has characterized many union struggles. While such a radical notion seems unfathomable, the early signs of this phenomenon are already emerging in Florida and California, where physician unions have been organized in response to reductions in autonomy, power, income, and clinical supports by payers and plans.

Alternatively, physicians may acquiesce to the forces of "corporate medicine" and relinquish any opportunity to lead the process of change. Hopefully, more enlightened organizations will acknowlege the benefit of the principles described herein and create collaborative and sustainable models for success that will rightfully subordinate the "business" of medicine to the practice of the art and science of patient care. This approach represents our best opportunity to achieve the Holy Grail of the "highest quality care at the lowest cost."

References

(1.) Champy, James. Reengineering Management: The Mandate for New Leadership, New York, New York: Harper Business, 1995.

(2.) Porter, Michael. I. Competitive Advantage: Creating and Sustaining Superior Performance, New York, New York Free Press. 1985.

(3.) Senge, P.M. The Fifth Discipline: The Art and Practice of the Learning Organization, New York, New York Doubleday/Currency. 1990.

Milo F. Pulde, MD. is Medical Manager and Medical Director at Brigham & Women's Hospital In Boston. Massachusetts. He can be reached by calling 617/278-0480 or via email at [e-mail].