Separately together--build unity by strengthening physician groups.

There is widespread agreement that effective physician/administrator relationships appear to be as bad right now as they have ever been. (1)

The issue is an urgent one. According to a 2004 survey of 480 hospital CEOs by the American College of Healthcare Executives, hospital/physician relationships ranked as one of the biggest worries, right after financial woes. (2)

We need to find a way out of the mess we are in. In the past, we have tried structural integration (legally combining the groups) as well as ideological integration (promoting a common dream) in order to instill a belief that "we are in this together." (3) All appear to have had little success.

We believe it is time to look in new places for answers. It's time to consider an uncommon perspective on hospital/physician relationships, based on evidence from recent social science research: (4) To bring together incompatible groups, you must first strengthen them separately.

Foundation for coming together

Social science research has demonstrated that people make sense of who they are based on similarities to the groups to which they belong and differences from the groups to which they do not belong.

For example, to the extent that you identify with being a physician, your understanding of yourself is determined in part by the medical groups to which you belong (e.g., cardiology), and by contrast to the groups to which you do not belong (e.g., primary care).

Social science research has produced interesting findings about intergroup conflicts. Two groups with very different beliefs about what is important will most readily support a common overarching purpose when each group already feels secure, distinctive and non-threatened.

When only the common identity is emphasized--de-emphasizing and threatening the separate group identities as either physicians or administrators--defensive reactions of turfism and tribalism are a likely result.

The findings provide insight into why efforts to unite physicians and hospital administrators toward a common purpose are so difficult. These groups have distinct, often conflicting perspectives on who they are and what is important.

The bases of knowledge, backgrounds, education and priorities of these groups point in different directions. (5) Attempts to emphasize that "we're all in this together" have not proven successful in most cases, (6) much like the social science studies would predict.

Loss of pride

Unfortunately, both physician and administrator groups have lost much of their sense of (and pride in) who they are as distinct and unique groups. This appears to be especially true for physicians. The specialization, sub-specialization, and sub-sub-specialization in U.S. medicine over the past three decades have fractured the profession into many splintered and often competing subgroups.

The medical staff as a negative force is quite powerful, able to block undesirable initiatives very effectively. As a positive force, however, the medical staff is often disorganized, impotent, reactive, and only comes together in response to a perceived threat. (7)

What this means is that physicians for the most part are a fragmented lot, viewing themselves as a group only in opposition to "what is being done to us." Most physician groups are not well organized; they have no uniting set of values or strategic plan for their group. Whatever group culture does exist is often oriented to preserving the very loose-knit affiliation rather than to developing a stronger physician organization. (8)

Building a strong, separate physician group

How can you develop a strong and united sense of pride in who you are as a physician group when the only thing pulling you together is the common threat of "them" taking away your autonomy and interfering with your work?

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Effective physician leadership is critical in shifting the focus away from "them" and perceptions of past wrongdoings toward "us"--physicians--in the present. Most physicians will no doubt initially have little interest in such endeavors. It is important to begin with a subset of physicians who are concerned and committed to forming a critical mass.

Once a critical mass of physician leaders has been identified, what specifically can be done to begin to forge among the rest of your physicians a strong sense of themselves as a cohesive and separate group?

First, leaders should establish frequent contact among their physicians. Given the time constraints, the contacts may need to be brief and should be structured around something meaningful to participants beyond opposing "them," which is often the only thread that has united the physician groups.

For example, a 350-bed community teaching hospital in the Northeastern U.S. was plagued with financial losses and troubled relations between physicians and hospital management. It convened a medical advisory panel (MAP) charged with determining and articulating the hospital's clinical priorities for the upcoming three years.

The MAP solicited regular input from the medical staff through a series of ongoing meetings and presentations with each clinical department about opportunities for improving patient service and reducing hassles for physicians.

Though the physicians initially expressed skepticism about the approach, encouraging the skeptical participants to openly voice their opinions allowed them to become part of the process and to feel that they were keeping the process focused on what they cared about most. (9)

Second, leaders should stress the similarities in the values of the physicians and promote the development of a common vision among physicians based on those values. Despite the fragmenting sub-specialties that create perceptions of difference, there is a lot that your physicians share in common, such as their concern for patient safety, their struggle for clinical excellence and their competitive enthusiasm for effective medical advancements.

For example, Kettering Medical Center, a 520-bed hospital in Dayton, Ohio, organized a "heart institute" with physician leadership among their cardiologists and cardiac surgeons. The common vision of these physician leaders, who were otherwise often at odds with each other, was grounded in a desire to improve cath lab utilization and case turnaround, technology acquisition and patient care in the CCU. (10)

Third, leaders must find ways to make membership in the physician group highly visible across the perceived boundaries that separate different groups of physicians. This can be done through newsletters, announcements, flyers or e-mail.

A 400-bed two-hospital system in the West began a promotional program in the community that featured key physician leaders in two cardiology groups that accounted for 90 percent of their inpatient cardiology care. This emphasis demonstrated respect for their value, their separateness and their clinical expertise, while at the same time implying common concern for excellence in patient care.

Fourth, leaders must find ways to enhance the attractiveness of "belonging" to the group of physicians from the system. Though granting certain benefits to go along with group membership undoubtedly enhances the attractiveness of belonging to the group, simply articulating and clearly and consistently communicating the prestige and value of the physician group may lead to the same end.

Finally, leaders need to develop a clear measurement system to monitor the value created by the physician group, and establish performance management systems that are relevant to those outcomes. Though data on physician performance are routinely collected and fed back to physicians, too often little is done with the data.

A recent study found that physicians and their colleagues looked at performance results, but felt no need to change the way they practiced as a result. (11) If the performance management system is developed for and by the physician leaders and focused on issues critical to physicians, physicians are more likely to care about the outcomes.

Physicians care about things that waste their time, make them wait, and treat them as a commodity. Successful programs work with physicians to identify metrics related to these physician concerns and regularly monitor and publish trend information for physicians about progress. Such metrics may include turnaround time in the OR, delays in administering medications, scheduling delays, medical errors prevented, public perception information and various clinical markers.

Why go through all of this?

First, we know that when individuals feel a strong sense of belonging to a group, they will have greater commitment to the group and to its purpose, they will exhibit more cooperative behaviors (e.g., sit on voluntary committee work/task forces) and demonstrate more citizenship behaviors such as referring patients to other physicians in the system and assessing what is best for the system. (12)

Second, we know that a strong and secure sense of self as a separate group leads to greater support for efforts that cut across groups. We are beginning to see evidence of this in health care.

A recent study surveyed 326 senior physician executives at hospitals and health systems to assess their view of the hospital/physician relationship at their institutions. (13) They found that the level of medical staff cohesion as a distinct and separate group correlated strongly with the level of physician support for organization-wide initiatives and with the success of physician/hospital relationships. That is, the stronger the identity of physicians as a group, the better their relationships with their hospital system.

Separately together

The ultimate desired end is for your physicians to feel strength in their separate and distinct identity as a physician group and at the same time to feel a bond of belonging to the health system in which they are working. It is neither necessary nor advantageous to engage in the "one or the other" see-saw that some have described. (14)

Instead, we are advocating a paradox of simultaneous separation and togetherness of the groups. Evidence from studies in social science research demonstrates that such a paradox is possible if each group has a strong separate identity before initiating attempts to bring the groups together. This is referred to as people holding a "dual identity," seeing themselves as both distinct and separate from "the other" and at some level united with that other. (15)

For example, based on a recent study, 30 percent of New England hospitals are working on at least one joint venture with physicians, but only 35 percent of those involved in a joint venture say it succeeds in aligning physicians and hospitals. (16)

And while hospitals around the country are generally attempting to rid themselves of physician practices because they tend to be losing propositions, North Carolina-based Novant Health saw its large physician practice (Forsyth Medical Group) move from red to black ink after it turned to its physicians for leadership.

Jack Thomas, MD, one of the employed physicians, stated that "it doesn't feel like we're employed. It feels like we're running a practice with a great deal of support." (17) That's the key: That people feel their uniqueness is maintained and their distinct contributions are supported.

Leo Bressanelli, CEO of Genesis Health Systems in Davenport, Iowa, described an example of physician/hospital alignment where the unique identities of distinct collaborating groups are being honored and maintained. The health system and the area's largest group of cardiologists have collaborated to create the Genesis Heart Institute.

Physicians offer diagnostic testing services and, across the skywalk from their offices, the hospital offers rehabilitation services. Bressanelli noted that it is "somewhat unique to have those centers side by side. One is an extension of the physicians' offices and one is an extension of the hospital's services." The institute is governed by a board of directors equally composed of physicians and health system executives. (18)

Integrated vision

What is the vision that can draw your separate strong entities together while at the same time allowing them to retain pride in their separate and distinctive contributions?

The components of the vision cannot be directly competing with the visions of either of the separate groups and cannot be the vision of any one of the groups alone.

If the overarching vision is perceived to be a threat to the interests and values of one of the groups (e.g., your physicians), the threatened individuals will tend to resist letting go of their past understanding of who they are, who the "other" is that is doing this to them, and how they should relate, blocking any possibility of embracing a new way of interacting.

For example, if a bottom-line margin is the centerpiece of the overarching vision, one would expect clinical team members to resist. And similarly, for a person in finance, a vision of providing the best clinical care at any cost may seem too far removed from fueling the economic engine that commands their support.

Focusing on each group's own distinctive contributions to an overarching vision makes it less likely that they will feel threatened and therefore undermine working together.

A recent report of Verispan's annual "IHN 100," which ranks organizations that are using higher degrees of integration to excel clinically and financially, described top systems such as Covenant Healthcare and Presbyterian Healthcare improving clinical outcomes and cutting costs because they are "connecting the dots," coordinating the interests of administrators and clinicians throughout their systems. (19)

While the "dots" do need to be connected, we argue that the connected dots need to remain separate, distinctive and non-threatened.

Maintaining the delicate balance

Assuming that you have strengthened the identity of the separate groups and then integrated them in a way that draws on their unique and distinct contributions, you are then left with the challenge of maintaining the balance between too much separateness and too much integration.

First, it is important to encourage people to regularly express their distinctive and different views in very public and supportive contexts. This preserves the paradox of simultaneous separateness and togetherness.

Second, leaders must continue to accentuate in a positive way the differences between the groups and the ways that their unique contributions make the efforts of the whole possible.

Importantly, behaviors that are encouraged and rewarded should not always be behaviors that make everyone feel like "they're in this together." Rather, rewards should also encourage behaviors that are focused on addressing real, pressing and common issues in which everyone plays their own unique and distinctive part.

Historically, administrators and clinicians have battled over which group should rightfully be the "captain of the ship" in health systems.

We think it's time to turn that age-old argument on its head. For relations between administrators and hospitals to be successful and sustainable, both sides must be captains of their own ships, and the ships must be moving toward a common destination.

Edward J. O'Connor, PhD, is principal with the Implementation Institute, a professor of management and health administration at the University of Colorado at Denver and Health Sciences Center and a member of the faculty of the American College of Physician Executives. He can be reached by calling [phone] or by e-mail at [e-mail].

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C. Marlene Fiol, PhD, is a professor of strategy and health administration at the University of Colorado at Denver and Health Sciences Center. She can be reached by phone at [phone] or by e-mail at [e-mail].

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Michael Guthrie, MD, MBA, is executive-in-residence and adjunct professor of health administration at University of Colorado at Denver and Health Sciences Center. H can be reached at 719-633-4966 [e-mail].

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References

1. Friedman LH. Editorial. Frontiers of Health Services Management, 20(2), 2003.

2. Evans M. "It all comes down to money: ACHE survey shows CEOs' big worries are fiscal." Modern Healthcare. January 3, 2005.

3. Burns LR, Anderson, RM, and Shortell SM. "Trends in hospital/physician relationships." Health Affairs, Fall 1993. Bujak J. "How to improve hospital-physician relationships." Frontiers of Health Services Management, 20(2), 2003.

4. Fiol CM and O'Connor EJ. "Divided and together we stand: Capitalizing on the paradoxes of belonging in hybrid identity organizations." Unpublished manuscript, 2005. Gaertner SL and Dovidio JF. Reducing Intergroup Bias: The Common Ingroup Identity Model. Ann Arbor, Mich.: Sheridan Books. 2000. Gaertner SL, Dovidio JF, Nier JA, Ward, CM, and Banker BS. "Across cultural divides: The value of a superordinate identity." In DA Prentice and DT Miller (Eds.) Cultural Divides: Understanding and Overcoming Group Conflict. New York: Russell Sage Foundation, 1999.

5. Shortell SM. Effective hospital-physician relationships. Ann Arbor, Mich.: Health Administration Press Perspectives. 1991.

6. Budetti PP, Shortell SM. Waters TM. Alexander JA, Burns LR, Gillies R and Zuckerman H. "Physician and health system integration: Public and private policies push physicians and health systems together, but they can also drive them apart." Health Affairs, 21(1), 2002.

7. Bujak J. "How to improve hospital-physician relationships." Frontiers of Health Services Management, 20(2), 2003.

8. Gillies R, Zuckerman H, Burns L, Shortell S, Alexander J, Budetti P and Waters T. "Physician-system relationships: Stumbling blocks and promising practices." Medical Care, Physician System Alignment Supplement, 39(7), 2001. Bujak, J. (2003). Bujak J. "How to improve hospital-physician relationships." Frontiers of Health Services Management, 20(2), 2003.

9. Cohn KH, Gill SL, and Schwartz RW. "Gaining hospital administrators' attention: Ways to improve physician-hospital management dialogue." Surgery, 137(2), 2005.

10. Guthrie M, Froneberger P, and Terry D. Survey of Better Performers in Cardiology. Premier, Inc. Charlotte, N.C., 2005

11. Gillies R., Zuckerman, H., Burns, L., Shortell, S., Alexander, J., Budetti, P. & Waters, T. (2001). "Physician-system relationships: Stumbling blocks and promising practices." Medical Care, Physician System Alignment Supplement, 39, 7, I 92-I 106.

12. Dukerich, J.M., Golden, B.R., & Shortell, S.M. (2002). "Beauty is in the eye of the beholder: The impact of organizational identification, identity, and image on the cooperative behaviors of physicians." Administrative Science Quarterly, 47, 3, 507-537.

13. Bard MA, Buehler ML, Epstein AL, Nash DB, and O'Connor JP. "Strong partners make good partners: Insights about physician-hospital relationships from a study of physician executives." Disease Management, 5(3), 2002.

14. Bacharach S B, Bamberger P and Conley SC. "Negotiating the 'see-saw' of managerial strategy: A resurrection of the study of professionals in organizational theory." Research in Sociology of Organizations, 8, 1991.

15. Fiol, C.M. & O'Connor, E.J. (2005). 'Divided and together we stand: Capitalizing on the paradoxes of belonging in hybrid identity organizations." Unpublished manuscript. Gaertner, S.L. & Dovidio, J.F. 2000. Reducing Intergroup Bias: The Common Ingroup Identity Model. Ann Arbor, MI: Sheridan Books. Gaertner, S.L., Dovidio, J.F., Nier, J.A., Ward, C.M., & Banker, B.S. 1999. "Across cultural divides: The value of a superordinate identity." In D.A. Prentice & D.T. Miller (Eds.) Cultural Divides: Understanding and Overcoming Group Conflict. New York: Russell Sage Foundation, 173-212.

16. Haugh R. "Are you looking for a fresh start with your MDs?" http://www.hhnmag.com, 6/14/2005.

17. Norbut M. "Physician input helps hospital-owned group make money." http://ama-assn.org. 4/7/2003.

18. Haugh, R. (2005). "Are you looking for a fresh start with your MDs?" http://www.hhnmag.com, 6/14/05.

19. Colias M. "Connecting the dots: Verispan's annual 'IHN 100' ranks organizations that are using higher degrees of integration to excel clinically and financially." Modern Healthcare, 34(5), 2004.

By Edward J. O'Connor, MBA, PhD, C. Marlena Fiol, MBA, PhD, and Michael Guthrie, MD, MBA

RELATED ARTICLE: Separately Together--Progress Assessment

Describe your progress toward building separateness and togetherness using the following statements by rating yourself on a scale ranging from

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1 Not Done

5 Successfully Completed.

In order to maintain the balance between separateness and togetherness, we have effectively:

1 2 3 4 5  Developed and explicitly articulated a clear overarching
           vision of what both groups value and can accomplish together.
1 2 3 4 5  Clarified the unique and distinct contributions required of
           each group to accomplish the overarching vision.
1 2 3 4 5  Consciously and strategically used inclusive language ("we")
           when referring to each of the groups separately or to the
           system as a whole.
1 2 3 4 5  Encouraged members of each group to express their distinctive
           views in public and supportive contexts.
1 2 3 4 5  Accentuated differences between the groups in positive ways
1 2 3 4 5  Established clear and measurable objectives to monitor and
           celebrate each group's distinctive contributions to the
           whole.

How does your progress look when compared with this list of winning practices? If some, but not all, of these components are in place, results are likely to be inconsistent, resistance high, and the process of change frustrating for everyone involved.