Leadership for the next millennium: the physician executive.
Some time ago I was approached by a doctor who had listened impatiently to my unflattering comments about the health care nonsystem and the need for change. He asked, "Why should we change the system? Our medical technology has produced some of the greatest medical achievements the world has ever seen. My hospital is replacing livers, opening up clogged coronaties, and curing many cancers. What's wrong with being 12.5 percent of the gross national product? That sounds pretty good to me."
Well, it is pretty good. This system has produced some miracles, both in treating the ill and in preventing illness. The oral vaccine for polio, returning to work only 10 days after a laser cholecystectomy, and an artificial hip in a 75 year old are only three from a long list of great accomplishments. They should not be overlooked or minimized. Any change that is forthcoming will do well to preserve the ingredients that catalyze this kind of achievement. But beyond the glow of today's marvels and the belief that tomorrow will produce more of them, there is a growing, gnawing feeling that something is very wrong.
The simple truth is that the system is broken. While its successes are well known, its deficits are so broad that few seem willing to wait for change by gradual evolution. And because of that, revolutionary changes will be sought in the next decade. To be sure, there will be resistance to any change, and there probably should be. Caution is prudent. But change will occur despite our caution. Coalitions previously not thought possible are demanding that we learn how to deliver preventive care and illness care in new and more effective ways. Labor and management are now speaking with one voice on this issue. Government, motivated by social pressure and a depleted bank account, will move with business and labor to further alter the system as we now know it.
Can you envision a new age health care system for the next millennium, one where concern for the environment, social idealism, and the triumph of the individual fuse into a powerful force to create a new paradigm? Marvelous technologies are created, and they revolutionize treatments. The hospital is no longer simply a body repair shop; it has become a restorative Mecca of holistic healing. The patient is in charge. There is universal access to basic health care for everyone. Community health care trusts guide increasing resources into more efficient and effective channels for those who are ill and into more plentiful prevention programs for those who are well. Health care becomes 20 percent of the GNP, and people are pleased with the value it has added.
Perhaps you believe another scenario is more likely. I'll call this one "hard times." Worsening budget deficits, an escalating medical arms race, and unhealthy life-styles fuel soaring prices. There are millions more without health insurance, producing even more political pressure for the typical American quick fix. With profits squeezed, employers search for more ways to control costs but find that shifting costs to employees is the only method that works. Small employers abandon health care coverage altogether. The working poor and the middle class are outraged and march on a Washington still reluctant to act. It explores options but finds that the peace dividend has been invested in failed financial institutions. There is precious little for health care. Congress finally responds by enacting reactive and restrictive health laws that bring hard times for this industry. Less is spent on sickness care than is spent now. Rationing emerges from the closet and becomes explicit policy.
Using another scenario, it may be competition, the American formula for success, that will rule the day. Efficiency, price, and market share become the most critical success factors. Hospitals and their medical staffs, finally united after years of self-destructive noncooperation, receive mail requests seeking their bid for next year's care contract. Caveat emptor is printed in italics on the last page of the employees' benefit plan. There's great innovation, creativity, and entrepreneurism, but price competition puts severe constraints on the budgets of teaching and inner-city hospitals. Twenty percent of U.S. hospitals dose. Most are rural or inner-city. Pockets of poor care and no care exist next to towers of technology, purchased by the most successful of competitors. The federal government mandates the play-orpay package. Although this system initially works quite well because of one-time savings, the basic system remains open-ended and inherently inflationary. Overhead and supervisory costs of pay or play are added to the budget and costs eventually rise dramatically.
What kinds of organizations will excel in these environments? What are the core values, skills, and attributes that will generate successful outcomes, earn public respect, and attract the best from tomorrow's workforce? Tomorrow's companies will see teams of individuals working together to design a better process, to build a better system. Quality improvement teams will be made up of front line workers, professionals, nurses, physicians, managers, and patients. Some teams will include purchasers as we recognize the value of collaboration in solving mutual problems. How do we prepare? What kind of leadership will be needed? Where will we find the leaders?
Assuming that leaders can be made rather than only born, I'd like to offer some cameos from the recent literature. Like Montaigne, I bring little of my own but rather offer the string that ties other men's flowers together.
Robert Fulghrums book All I Ever Needed to Know I Learned In Kindergarten is a strange place to read about leadership, but it contains several simple truths. "Share everything," he writes. For kindergartners, that means sandbox toys and crayons; for managers it means tools, information, and the lessons of experience. Say you're sorry when you hurt someone. Play fair. Don't hit! Put things back where you found them. Clean up your own mess. Watch out for traffic. This seems to me to be good advice for living, for family and for work.
Max DePree is the President of Herman Miller, voted one of the best companies to work for in America. His book, Leadership is an Art, is a compendium of ideas, examples, and stories about leading. Leaders, he says, listen. They listen to the ideas, needs, aspirations, and wishes of followers. The first responsibility of leadership is to define reality, to say thank you, and to serve. The servant leader is, ultimately, the principal steward of relationships, of civility, and of values. We can measure the success of these leaders by the wake their followers leave: Did they reach their potential, did they learn, did they too serve, did they achieve results? DePree seems to have tomorrow's organization in sight when he asks his employees, "Would you rather be part of an outstanding group, or part of a group of outstanding individuals?" His followers chose the former--the outstanding team.
"Team" is a common word in the leadership literature. Tom Peters in In Search of Excellence describes teams who speak with one voice. Leaders who build teams create purpose, shape values, make meaning, and listen. They seem to recognize our need for meaning in what we do and why we do it. Peters observed that team builders are visible when things go wrong and invisible when they go right. In Peters' Passion for Excellence, we read stories of coaching, sponsoring, teaching, and love.
Leadership has little to do with cheers, parades, and doing what feels good. It even has little to do with balance sheets, negotiation, and general systems theory. As important as these skills are to setting a direction, they won't produce the changes we need. Leadership is about people; it's about sharing, respect, coaching, cleaning up, serving, learning, purpose, and listening. Leadership is about values and vision and future time.
Where are you going to lead your organization, your family, yourself? What values are you going to protect, defend, and teach? What future can you create for health care? The health care system of the future will be very different. Its organizations, institutions, and its people will also be different. The future successful organization will be committed to innovation, where there is no fear of ridicule or reprisal for inventing new and creative solutions, where teams of people are coached on how to go about continuously improving the quality of services or products, and people. Where the individual triumphs through participation and empowerment. Can you see your organization committing to long-term goals such as the growth of individuals and the measured betterment of an entire community's well being? To cultural diversity that catalyzes a richer tapestry of commitments? The learning organization and its leadership carefully examines, analyzes, listens, sees, feels. It examines and studies. Instinct is not enough.
The leaders who can create these organizations will, as Tichy describes in the Transformational Leader, clearly see themselves as change agents, courageous in their plans and believing in the people they serve. They will challenge what's so, take risks, and encourage innovation. Despite complexity, ambiguity, and uncertainty they'll articulate a vision, inspire, and empower. Because tomorrow's organization will be values-driven, leaders will encourage the heart as well as challenge the mind.
Regardless of which scenario you select from those reviewed here, you'll find that organizations that flourish in the next decade will address several critical factors. First is quality and its continuous improvement. There is now more than ample evidence that the lessons learned from the total quality management movement in other industries can be applied successfully to health care. Quality improvement teams in hospitals have dissected our complex processes and systems, rebuilt them, and made them more efficient. Physician teams are taking apart clinical prescribing habits and eliminating the unnecessary and the redundant to improve quality and reduce cost. System theory, diagnostic skills, and scientific thought, including a working knowledge of the systems of health care delivery and diagnostic decision making, are important to the TQM process. I believe the physician executive can bring value to this process.
Another critical factor is our search for ways to accurately measure the outcomes of our interventions. Utilization management, and its brother outcomes management, will require a team of professionals to separate the useful from the marginal and the effective from the ineffective. The establishment of preferred practice patterns will greatly improve collective control of costs, and cost control is a critical success factor for the nineties. Clinicians in leadership positions will be crucial to the implementation and evaluation of these strategies.
We are moving toward great change in how health care is paid for. Resource-based relative value scales place limits on the fastest growing sector in health care costs--the clinician's bill. Mandatory Medicare assignment may soon follow. The foundation for a single payment per admission or perhaps per episode of illness is not far away. Indeed, the Health Care Financing Administration has already started pilot programs to evaluate the completely bundled procedure fee. What will be the role of physician leaders in negotiating, managing, and evaluating contracts let in this fashion? I believe they will bring added value to the table.
There dearly are additional critical success factors for the nineties. The list includes building alliances between hospitals and their physicians, alliances between hospitals, and alliances between hospitals and purchasers. In direct contracting with regional businesses, having a skilled medical director at the table has been beneficial to both sides. Preventing illness is clearly the most desirable route to significant cost reductions. Those who can bring clinical expertise and health plan design to the problem-solving table will offer great value to providers, purchasers, and patients. Economic credentialing, cost-quality choices, ethics, and managed care and its cousin practice guidelines will gain increased importance. The physician executive will contribute to this transition.
There has been tremendous growth in the field of medical management during the past 10 years, and it will continue. Some organizations will select physicians as their CEOs and presidents. Organizational history and structure may have already set that course. Of the seven or eight percent of U.S. hospitals that have physician CEOs, most are major group practices or academic medical centers. Virtually all are large organizations. It's not too likely that their number will change appreciably. The real growth will come at the departmental level--the full-time medical director, the part-time medical director, and the department chairman. These positions will be key to addressing the critical success factors for organizations in the next decade. It seems inconceivable that success in any of the scenarios I've described will not require the successful integration of the medical model and the management model. Physician executives will not be at the table to replace but rather to collaborate, to bring their unique perspectives to the team problem-solving process.
The transitions will not always be easy. Administration and medicine have a long history of conflict and distrust. Current economic incentives encourage different goals and reward different behaviors. It's not clear to some managers that the fox could be very helpful in guarding the chicken coop. It's not clear to some physicians that some managers can understand enough of clinical practice to design its future processes. The successful organization will reverse those traditions. It will find the resources and create the environment where mutual education and skills development are part of the culture. Learning organizations that can become integrators of resources and collaborators for innovation will become the leaders in the next millennium. Physician executives and nonphysician leaders in combination will make a powerful catalyst for improvement.
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|Author:||Klint, Robert A.|
|Date:||May 1, 1993|
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