The new management team. (Shared Management).

A SPIRITED DEBATE CONTINUES ON THE MUTUAL roles of physicians and nonphysicians in the management and governance of health care enterprises. Much of the debate and the spirit in which it is conducted is the result of the "intrusion" of physicians in a management domain that has long been occupied and controlled by nonphysicians. This is most true in hospitals and other institutional settings and in the upper echelons of managed care organizations. It is less true in medical group practices, and, it seems to us, that makes the latter an ideal setting for testing a new form of shared management that will help to rid organizations of the confrontational and adversarial attitudes that have too long characterized relationships among managers and clinicians in our health care organizations and institutions.

The opportunity to jettison past attitudes and relationships is advanced by the emergence of a new breed of physicians, with outstanding clinical credentials and knowledge of and interest in the larger issues of management and policy. The success of these new physician specialists, and of the organizations they serve, can only be achieved if nonphysician managers acknowledge the important role of clinical decision-making in overall organizational operations and if clinicians accept the cost of a physician colleague's elevation to a management role.

Importance of team approach

Health care delivery has always been a "team sport," but its increasingly institutional and organizational flavor makes team approaches ever more important. The financing and delivery of health care is an immensely complex undertaking. No single profession or employee group can expect to successfully direct all or even part of the health care delivery enterprise without meaningful input from a variety of collaborating and cooperating colleagues. Decision-making must be shared.

This notion is obvious at the point of patient care. Physicians, nurses, therapists, and a host of other providers routinely work collaboratively among themselves and with an array of ancillary health professionals to ensure that patients receive high-quality, cost-effective care. When this model fails to deliver on all its goals, the proximate cause is usually a breakdown in the spirit of cooperation and collaboration. One or more of the 'people' elements attempts control of the decision-making process. All can be guilty of this infraction, although physicians and financial decision-makers seem to be the most frequent offenders. Physicians all too often wish to make clinical decisions, irrespective of financial consequences, and managers often wish to make financial decisions without adequate consideration of clinical consequences. The result is that the team becomes a collection of minimally cooperative, even warring, parties.

There is no better place to instill the necessary sense of cooperation and collaboration than the top. If top management, both physician and nonphysician, can establish a suitable working relationship, and communicate both the necessity for and success of the relationship throughout the organization, the aforementioned breakdowns are far less likely to occur. Shared responsibility and decision-making at the upper levels can be a laboratory for their use in other organizational locations, The partnership between clinical and administrative leadership is more important now than ever before.

Make no mistake about it, however. A useful division of labor exists in the changing relationship between physician and nonphysician managers. Physicians bring to health care management knowledge of and experience in clinical care that nonphysicians simply cannot match. When the need is to convince clinicians of the advisability of making practice and operational changes that will sustain and/or advance an organization, the message will always be received best from a clinician colleague, especially if that colleague has been in a position to gather input from clinicians and use it to shape the proposed changes. Acquiescence of clinicians to the changes will not be easy, but its path will at least be eased by the clinical credibility that the physician manager enjoys.

But the nonphysician manager almost certainly enjoys the respect of his or her nonclinical constituents for the management expertise that he or she has long brought to the enterprise. They will be looking for assurances that their needs and values are being tended to by the nonphysician manager. As is usual for a smooth-functioning team, the partners bring synergism to their relationship, but they must be attentive to the fragility of their relationship and of its need for care and feeding if they expect outcomes that will keep the organization healthy.

Mix of distinctive and shared responsibilities

Clearly, the relative roles will mesh best if they have a mix of distinctive and shared responsibilities. Through mutual consultation, many seemingly easy solutions will be discarded, and there is a better search for new ideas. Where decisions have no or little impact beyond clinical operations, the decider should be the physician manager, with minimal involvement of the nonphysician manager. For instance, the physician manager or his or her delegate would be the final decision point for matters involving selection of medical staff members. Likewise, where decisions have little or no impact on clinical operations, the nonphysician manager would make the call. For instance, a decision on where to place excess cash needs no clinician input. For a matter such as the purchase of major clinical equipment, both parties should be involved.

The key is for the two managers to agree up front on how responsibilities will be distributed and on how decisions will be made on new responsibilities. To be avoided as much as possible is the perception of either party that the other has overstepped his or her bounds. Ideally, the two senior managers--clinical and administrative--talk about decisions on a daily basis to be sure each is aware of the other's activities. Typically, errors occur when the decision-maker doesn't perceive that his or her counterpart must be involved.

All of the aforementioned presumes equal partners, probably with some joint title, such as co-executive officer. Alternatives could be a physician CEO and a nonphysician COO, or vice versa, as long as the operational relationship is clearly stated and just as clearly understood. Critical to success, and to the avoidance of unnecessary tension or conflict, is agreement up front on exactly how the two will work together.

To achieve a leadership role, the physician manager will have to acquire at least a basic set of management skills--finance and financial management, human resources management, marketing, organizational theory and practices, information systems, health care law, and a large set of interpersonal behavior skills. Here the nonphysician manager is likely to own an advantage. He or she will have spent many years acquiring and applying these management skills, and will likely enjoy more in depth familiarity with them. Some physician managers will justifiably use their clinical expertise and newly acquired management skills as a springboard to participate at the highest level of health care management. But most will be satisfied to make a difference closer to where issues of organizational management and clinical practice coincide. Some will opt for a management role; others will remain in a clinical management role.

Management partnerships

There is a management partnership arrangement inherent here that is too infrequently put into practice. The National Health Service of Great Britain uses a troika team of nurse, physician, and administrator to manage its hospitals, (1) and both in the U.S. and abroad there are examples of institutional departments co-managed by physicians and nonphysician administrators. (2-4) The evidence is that these arrangenents all work well, even if imperfectly. In Great Britain, very large hospitals and health care systems operate under the troika. Where understanding of the division of responsibilities and of individual responsibilities exists and methods of negotiating differences are in place, the system works well. (4) An ever-present danger is failure to achieve consensus, but the danger's very presence seems to create a condition for resolution. The enterprise becomes unwilling to court the results of total failure. (4)

A search of the literature disclosed no examples of U.S. health care enterprises in which decision-making is shared in the way contemplated here by physician and nonphysician managers. Reports are entirely theoretical. However, we do not believe that the absence of evidence of success detracts from the proposal. What the arrangements seem to suggest is that the modern health care enterprise cannot be managed as well from the narrow perspective of any of the potential management partners as it could from their joining as a team of equal members to accomplish the management task. In reality, many group practices are managed by a clinician/administrator team. The arrangement is often in the form of an executive director and a clinic president, medical director, or board chair. In small clinics, all of the clinicians may be able to participate in decisions with the administrator/manager. The group practice setting is an ideal place for more of these partnerships.

Drawbacks

Obviously, such an undertaking would not be without its drawbacks, but we believe that they can and must be overcome. First, a joint management arrangement presumes an ability to forge a trusting. cooperative relationship. Further, that relationship must be visibly demonstrated to the physicians and nonphysicians who will look to the team for leadership. It will be much easier for the two partners to strike such a relationship than to convince subordinates that it exists.

And it is predictable that subordinates will quickly pounce on any perceived absence of trust and cooperation at the top and use it to undermine the entire effort. However, if the partners are able to routinely arrive at mutually agreeable decisions after open and honest airing of the issues and of their differences, resistance among employees should be dissipated. In the beginning, differences, especially public differences, between the partners are likely to ignite what will already be a tinderbox. However, after experience has been gained with the process, it should be possible to air such differences and gain input from employees.

A good example is a change in clinic hours--for instance, the addition of Saturday morning hours for a clinic that has adhered rigorously to a Monday through Friday schedule. First, any decisions on this issue are apt to touch the entire staff of the clinic, so communication must be total and acceptance as complete as possible. Neither the physician nor the nonphysiclan manager can make any decisions unilaterally. They must stay in constant communication on the issue, communicate fully with staff and obtain the widest possible input, and aim for near unanimity on the final decision. Any sizable pocket of resistance will doom the new clinic hours, even if the two managers agree.

So, both parties must be highly amenable to negotiating their way to final decisions. Neither party can operate by dictum. And failure to arrive at decisions is a tolerable outcome for only the most insignificant of issues. The issues that drive the enterprise will require resolution, so each party must work hard for the win-win outcome. As mentioned earlier, impasses are likely to ignite a tinderbox. A useful course of action in the face of an impending impasse would be, as already described, to seek input from employees.

Constituents will be carefully scrutinizing the activities and decisions of the partnership for any evidence of unbalanced power. Clinicians will expect their views to receive a full airing from the physician manager partner. Nonclinicians will similarly look to the nonphysician manager partner for these assurances. If the partners do not attend to the arrangement dutifully, constituents expectations could easily corrupt their efforts at harmony and cooperation. It will be the responsibility of the partnership to imbue the organization with a spirit of cooperation and trust.

Of course, there are other drawbacks to these arrangements that must be acknowledged. The clinician manager will have to remain in a clinical capacity at least some of the time. This makes life hard for the clinician in a management role, but clinicians in a group practice are loathe to have a physician manager who doesn't do any clinical work. This is less so in the largest group practices, but it is true in most cases. Except for very large group practices, of course, the organization may not be able to support salaries for a full-time administrative executive and a part-time or full-time physician manager.

Conclusion

Regardless of these and other potential problems, the notion of cooperation rather than confrontation between physicians and nonphysicians is certainly a concept worth exploring. A realistic first step would be to make the operational and mindset reengineering that will be required the subject of the next board retreat for the group. Old habits will not be overcome by fiat. All parties will have to air their concerns and participate in a debate that moves the organization toward the 21st Century.

References

(1.) Mark, A. "Developing the Doctor Manager; Reflecting on the Personal Costs." Health Services Management Research 8(4):252-8, Nov. 1995.

(2.) Skelton-Green, J. "Leadership Crisis in Psychiatric Services: A Change Theory Perspective." Psychiatry Quarterly 68(1):43-65, Spring 1997.

(3.) Toussaint, J., and Correia, K. "Integrating Acquired Physician Practices." The Physician Executive 22(10):33-5, Oct. 1996.

(4.) Brotherus-Kettunen, A., et al, Motivational Patterns of Management Team Members in a Large Hospital." International Journal of Health Planning and Management 5(1):73-80, Jan.-March 1990.

Barbara LeTourneau, MD, MBA, CPE, FACPE, is Vice President, Medical Affairs, North Region, at Allina Health System in Friday, Minnesota. She can be reached by calling 612/780-6890, via fax at 612/780-6783, or via email at [e-mail].

Wesley Curry is Managing Editor, Book Publishing, at the American College of Physician Executives in Tampa, Florida. He can be reached by calling 800/562-8088, via fax at 813/287-8993, or via email at [e-mail].