CMOs: the new generation.
Look at how the role of the CMO has evolved to take on physician management, quality and patient safety, regulatory compliance, governance and system-level responsibilities.
One of the most rewarding elements of our work at VHA is the opportunity to interact with the chief medical officers (CMO) from our 1,400 hospitals. Over the past 15 years, we have had the privilege of working with them on performance improvement and patient safety initiatives, meeting with them at VHA's National Physician Leadership Councils and conducting phone interviews to develop a thorough understanding of their issues and challenges.
From our vantage point, the roles and the responsibilities of CMOs are undergoing rapid and dramatic changes. What might once have been a role perceived by both doctors and management as a thankless go-between has evolved into vital element in the operation of American health care organizations.
A decade or two ago, CMOs primarily were concerned with facilitating the work of the medical staff organization and the medical executive committee. They supervised privileging, credentialing and peer review activities and acted as liaisons between the medical staff officers and the hospital administration. They also provided strategic input to executive management.
Over the years, as clinical performance and patient safety have become progressively more important, many organizations extended the role of the CMO to include managerial oversight of these activities.
As form follows function, the design of CMO roles intended to function within an environment where independent practitioners provided most medical care, including hospital-based medical care. In that setting, physicians came to the emergency department to see their own patients, took care of them while they were in the hospital, and provided on-call coverage for emergencies and unassigned patients. They prized professional autonomy and defended in vigorously. At least in theory, physicians and hospitals were not in competition with one another.
In order to carry out these functions, hospitals recruited most CMOs based on their personal and clinical reputations, and their ability to deal with the human issues that dominated the relationship between the hospital and the medical staff.
Although they often had some managerial responsibilities, the number and level of staff members reporting to them did not warrant sophisticated operational or management skills. Organizations prized advanced degrees in business, information technology, law or public health highly, but these were seldom job requirements.
Times have changed and there has been a fundamental shift in the way doctors relate to hospitals. Large numbers of medical staff members no longer have compelling reasons to frequent hospitals. Many physicians--those in primary care in particular--find greater productivity working in their offices rather than rounding on small numbers of inpatients.
Health care organizations have backfilled this shift by hiring or contracting trained emergency department physicians, intensivists and hospitalists. Lack of personal involvement by independent physicians and the hospital has accelerated the erosion of the voluntary service paradigm; in many communities, physicians now decline call or unassigned patients unless they receive payment for their services.
A second important trend has been the rapid evolution of and increased reliance on performance improvement activities. Pay-for-performance programs incentives can be the difference between a profit and a deficit for more and more organizations. Public reporting on clinical and patient safety performance can influence patient revenue and physician recruitment significantly.
Initiatives like Six Sigma and Lean augmented the "Plan, Do, Study, Act Cycle of Improvement" (PDSA) methodologies. The number and sophistication of staff members necessary to implement these advanced methods have increased accordingly.
There is also a seemingly irresistible march toward implementing advanced information technology. Hospitals are investing hundreds of millions of dollars in medication bar coding and electronic patient records and computerized physician orders. Some organizations also rely on information technology to attract community physicians who cannot afford or do not want to take on the burden of electronic health records.
While external vendors can supply hardware and software infrastructures, only the organization can address the cultural issues of autonomy and standardization and the effect on work processes issues.
Regulatory requirements continue to expand, as well. Peer review processes, credentialing, ongoing monitoring of physician performance, providing detailed reports to various state and national agencies, reacting to patient complaints and improving customer satisfaction are all on an increasingly upward path.
Lastly, CMO challenges are more likely to extend beyond a single facility. Although each facility has a unique culture and its own elected physician leadership, bylaws and history of relationships with the medical staff, a growing number of health care systems are consolidating individual hospitals on the premise of economies of scale. In those organizations, the physician leader has the opportunity to work across multiple hospitals and micro-cultures to influence the care delivery of an entire system.
In our conversations with CMOs, it is evident that these changes are happening everywhere in the country. The overriding trend is that, regardless of local issues and priorities, there is a steady migration from the historical role of facilitation and liaison between administration and medical staff toward increasing responsibilities for operational management.
Perhaps the biggest challenge today is the management of the steadily growing numbers of physicians the health care organization employs or contracts with. Today, hospitals typically find themselves owning or contracting with the ED doctors, hospitalists, anesthesiologists, intensivists, pathologists, radiologists and trauma surgeons. Many more are finding that to supply important services needed by the community, they must employ neurosurgeons, cardiac surgeons, neonatologists and urologists.
In addition to full-time physicians, there are the part-time medical directors, doctors paid for taking call and paid arrangements for attending committee meetings. Joint ventures, gain sharing and any number of other financial relationships have evolved over time and require negotiation and leadership. Finally, hospitals engage in strategic initiatives to develop a community presence, such as by staffing primary care clinics.
If there is one lesson that we can take from the fiascos health care organizations experienced during forays into physician contracting in the 1990s, it is that most hospital administrators know little about the business of running physician practices. A corollary finding is that the majority of physician practice manages, even successful ones, do not know much about running hospitals.
In hopes of finding an effective agent to fill this void, the CMO usually becomes responsible for making things work. Increasingly, CMOs find that they actively are involved in the recruitment, hiring and management of employed and contract physicians.
In fact, large organizations such as Carolina Medical in North Carolina, Our Lady of the Lakes in Louisiana and Memorial Hermann in Houston have created a second CMO position just to deal with physician issues and to free one CMO to focus on quality and safety issues.
Quality and patient safety
The CMO's responsibilities for clinical performance and patient safety increased exponentially since the publication of the Institute of Medicine reports beginning in 1999. External parties such as The Joint Commission, CMS, health plans and the public media have become gradually more interested in the performance of health care organizations and have instituted mandatory reporting for dozens on measures, generating a heavy burden.
Frequently, organizations now employ dozens of nurses and other clinical staff members who end up collecting data for reporting purposes for the majority of their work hours. A second burden is managing the improvement process. Another group, usually well trained in performance improvement techniques, constantly works to tackle both clinical and operational issues.
Thirdly, since many of the innovations require signoff from both hospital committees and groups of specialists, coordination with the medical staff has become a major consumer of CMO time.
Quality is a reflection of patient care, and more and more, quality links to hospital revenues. Pay for performance programs will continue to strengthen the link between quality measurement and hospital revenues.
Yet again, larger organizations have begun to delegate responsibilities for these functions. Many CMOs now have quality officers and safety officers reporting to them. Organizations are starting to recognize the importance of information systems for resolving performance issues and reducing the measurement burden. As a result, a growing number of medical information officers report to CMOs.
Regulatory and accreditation requirement continue to expand. The most conspicuous of these are The Joint Commission and CMS, but there is a plethora of other local, state and national organizations. CMOs and chief nursing officers typically own clinically related regulatory issues. While visits from The Joint Commission usually involve only four or five days on site, but preparation and follow-up for such visits can take months of staff and CMO time.
A key focus of regulation continues to be the monitoring of medical staff members' capabilities and performance. Whereas in the past it was possible to process an application for staff privileges or credentialing for a new procedure based on a few letters of recommendation, each application must now be thoroughly vetted using both local and national databases.
Ongoing performance is another key activity, with new sources of input such as HCAHPS data. Although the medical staff organization and board make the final determinations, ultimately the CMO is responsible for ensuring that the information needed is complete and in compliance with national requirements.
While boards are no less interested in operational and financial information than before, their focus is now more on the clinical performance of the organizations they oversee. Because of programs such as Institute for Healthcare Improvement's Boards on Board, quality and patient safety committees have become one of the most important elements of governance in many hospitals.
Although the compositions of the committees vary, the CMO is a constant fixture. Educating community leaders about patient safety issues, gaining their support for needed programs and sharing information about complications has become one of the CMOs most important activities, but unlike other issues discussed above, they cannot delegate these issues easily.
Working at the system level
If things are not complicated enough, CMOs face another challenging issue. Multi-hospital systems are becoming progressively more common. While each facility will find strengths in its unique medical staff and community, there is no room for shoddy quality and patient safety.
The system-level CMO is now responsible for programs at multiple locations. The system-level CMOs we have spoken to have little role consistency. Some have hospital-level CMOs at each facility reporting to them. Others have installed quality assurance and performance improvement staffs locally, but address credentialing, privileging and the development of clinical policies at the system level.
Still others reserve physician management activities under one system-level CMO, with quality and safety under another. Finding the most effective way to manage this new level of complexity appears to be a work in progress.
Implications for education
Today's CMO faces an increasing array of technical and operational challenges. In the past, these activities took a relatively small share of the CMOs time, such that a given CMO could manage them personally. Given the expanding breadth and complexity of their responsibilities today, most CMOs have little choice but to find a way to delegate some of the work to qualified staff.
This means people and project management have become ever more important in the CMO skill set. As a result, more physicians interested in this line of work are earning graduate degrees in business, public health and even law.
For physicians looking to make a difference in the quality, safety and efficiency of health care, there are few opportunities that match those of today's CMO.
Vice president and leader of physician strategies for VHA lnc.
Vice president of clinical improvement Services at VHA Inc.
By Peggy Naas, MD, MBA, and K.W. Smithson, MD, MBA
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|Title Annotation:||Special Report: Chief Medical Officers|
|Author:||Naas, Peggy; Smithson, K.W.|
|Date:||May 1, 2009|
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