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Physician leadership is key to creating a safer, more reliable health care system.

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This position paper by ACPE's President and CEO outlines the value of physician leadership and explains why leadership and business activities must start and end with the patient's clinical needs foremost in mind.

Unemployment, home foreclosures, and a rising percentage of uninsured families are just a few of the casualties of the recent downturn in the economy. With these developments, there are growing questions about the ability of our health care system to handle the social and medical fallout of these stresses on individuals and businesses. With our current system of health care finance and delivery, even if the financial sector is stabilized, health care coverage, cost, and access issues are likely to plague American business for years to come. Therefore, it is reasonable to believe that major opportunities for change will emerge from the current chaos of our economy and health care industry.

Combined with the economic factors affecting health care, we are facing a shortage of primary care physicians. This shortage will become even more apparent if universal coverage becomes reality. We believe primary care physicians need to be prepared to lead groups of mid-level health care professionals, who will become the more convenient and less costly alternative to most physician-patient encounters of today.

We are hearing from physicians and health systems across the country that economic pressures are pushing physicians and hospitals into integration discussions--again. Not wanting to repeat some of the failed experiences of integration in the 90s, both sides are trying to find fresh approaches to working together that are more satisfying and productive.

This article will describe what physicians can do to be a force helping to create positive change within health care. We will show how a new and more effective business model for health care delivery should leverage a clinical model that is focused on a patient or consumer. Building on the concerns, priorities, and decisions made by patients and their physicians, we believe that health systems can no longer view clinical activities separately from management and administration. Leadership and business activities must start and end with the patients' clinical needs foremost in mind.

It is a model that should resonate with all other clinicians as well as our managerial colleagues on the health care team. It will require us to be open and curious to new ideas from science and business with a goal of improving reliability and outcomes and reducing waste and inefficiency. Regardless of partisan preferences for specific models of finance and delivery reform, the clinical model is applicable and adds significant value and focus.

Changes coming

Patients are generally dissatisfied with the health care system's access, cost, and quality. (1) A large percentage of our population believes the system is in need of major overhaul. Our health care colleagues share the public's opinion. The clinical workforce in our nation's hospitals finds frustration in their work environment on a daily basis, and cites frequent and recurring patient safety issues. (2) Our health care system spends more per capita than any other developed nation, yet on many quality indicators we have significant shortcomings. (3) In addition, the continued rate of health care cost increases is a major threat to the long-term health of our economy.

Until recently, the American economy, with its emphasis on consumer marketing and choice, demonstrated unstoppable growth. Health care continued to grow as a percentage of GDP, often adopting the same consumer marketing concepts common in department stores or hotels. The health care customer experience is the primary concern of the health care system, using metrics common in retail businesses--staff courtesy, ambience, and food quality--rather than metrics focused on true quality of care or patient safety. Health system strategic and financial decisions are often based on these consumer metrics, instead of first identifying whether those metrics really represent the patients' foremost concerns. Clayton Christensen, in his book The Innovator's Prescription: A Disruptive Solution for Health Care, suggests that hospitals and health systems should "deconstruct" their operational activities (4) to determine whether the enterprise provides highly reliable and specific solutions to consumers' problems, or adds value to common processes or experiences. This is very different from offering everything to everyone, which is how many department stores or auto companies have viewed their business models.

The separation of management from clinical work as two distinct and unrelated activities in the health care system must change. With patient safety and high reliability of the system as our main purpose, the activities of both clinicians and managers, from the executive suite to the bedside, can be integrated. We can learn from our management colleagues how to mobilize an entire organization and then leverage the clinical model, as a unifying force for the multidisciplinary health care team

This "clinical model" has its roots in our oath to "first, do no harm" and two additional concepts. Together, these three principles can provide a common focus that will enable the business and clinical goals of health care organizations to become more tightly aligned.

Do no harm

The driving force of health care reform--the value proposition of the clinical model--can be the same powerful admonition that all clinicians learned on their first day of training. In Latin: Primum non nocere. First, do no harm.

Clinicians from the bedside to the operating room to the executive suite all share this sacred duty and responsibility. Enlightened leaders and managers--even those without clinical backgrounds--find primum non nocere to be a powerful management beacon that explains what we must all do together to protect our patients, even when economic considerations might drive us to generate additional health care services that do not benefit or might pose risks for patients..

The science of high reliability should be a core competency of health care leaders because it teaches us how small events in a complex system often lead to catastrophes downstream. (5)

This engineering science describes the links between leadership and front line activity in high consequence work as "blunt end-sharp end" connections that define whether all employees are engaged or disengaged in doing work that is highly reliable. Whether we work at the "sharp end" (the front lines of patient care), or the "blunt end" (management, leadership, governance, or regulatory agencies), (6), (7) of the health care system, a physician's overriding concern is not causing harm.

Instead of using management philosophies and accounting practices common in running a department store or hotel, a more realistic analogy for our "clinical model" of health care management would be a commercial airline, (8) where safety of passengers and crew is the most important concern of leaders. Recent surveys of health system CEOs show that quality and patient safety have become the top priority for the next three years (9)--a very encouraging development.

We believe that quality and safety should always be the core competencies of health care--not priorities that change with time. Imagine what different metrics would be discussed among boards and executives if safety and high reliability were the strategic heartbeat of health care organizations!

Well-defined engineering principles in high consequence activities such as aviation, fire fighting, nuclear power, and electrical power have relevance to health care. The IOM report "To Err Is Human: Building a Safer Health System" suggests we can use these principles to understand error in health care. (10) Better yet, we can learn techniques to minimize the chances of human and organizational contributions to error. (11)

Evidence-based medicine

The second key leadership philosophy for the clinical model of health care delivery is analyzing and solving problems using evidence-based approaches. In clinical practice, we can use growing databases of evidence-based guidelines and studies to focus our energies on making sure that our patients are not over- or under-treated, and show that we produce consistent incremental improvement in the application of these guidelines.

We are learning a great deal as we begin to embrace evidence-based medicine. Although standardizing processes is important, we must avoid the trap of becoming obsessed solely with process improvement, and have at least an equal focus on improving outcomes. (12)

Not all physicians embrace evidence-based medicine or routinely follow guidelines. There are many reasons and barriers physicians face in adopting clinical standards, even when the evidence supporting them is compelling. These include lack of knowledge of the evidence, disagreement with the standards, practice-based impediments to implementing new practices, and the inability to overcome the inertia of prior practice patterns. (13) Once again, physicians in practice and in formal management roles must lead others to adopt evidence-based practices by serving as champions for doing what is proven to work. The end result of this approach is not only improved quality of care but also lower health care costs due to a reduction in health care services that are not indicated by evidence-based medicine.

Patient-centered teamwork

The third key leadership philosophy of the clinical model is patient-centered care. Most important to patients is getting their questions answered in terms they understand, addressing their fears and uncertainties, and mapping out a course of preferred action to deal with their health problems.

Patient-centered teamwork means supporting patients who disagree with our recommendations if their individual preferences and lifestyle considerations differ from our own. Patients and their families need to know what action steps can be taken if progress is stalled.

Since most health care processes involve many health care workers other than physicians, we need to encourage teamwork, critical thinking, and openness to questions from all of our colleagues, including executives and managers. We should also consider when to abandon our need for absolute autonomy for the sake of the greater good in patient care.

As we work with others to improve quality of care and reduce unnecessary medical costs, we must strive to implement clinical services that have been shown to work and help patients--and reduce utilization of services that have little evidence to support their use. We must provide leadership in this domain, as many costly diagnostic and therapeutic technologies are overused in the current fee-for-service system that rewards clinicians for their use. Overuse also increases the possibility of harm to patients.

For many patients and families, the appearance and customer experience of the hospital is a proxy for quality. Though these attributes are important, they should never displace primum non nocere and outcomes metrics as the driving force of health care organizations.

Embracing a clinical model of leadership

We believe that physicians who ascribe and practice these three simple leadership and management principles will become a powerful force for change in health care. Jim Collins, in his best-selling business book Good to Great, describes the highest and most effective form of leadership as Level 5 Leadership. Some of the practices used by these leaders include "leading with questions, not answers," and conducting "autopsies without blame" when something goes wrong in the organization. (14) To foster this approach, we agree with the 28 physicians of the University of Southern California's Masters in Medical Management Program at the Marshall School of Business that, "the seed for physician leadership needs to be planted as early as possible in the medical education process." (15)

Physicians can be the Level 5 leaders of health care who treat all their colleagues with respect, reinforce positive feedback on performance, and never use intimidating or threatening behaviors in dealing with their team. We can rekindle the curiosity that led us to our clinical careers and use that excitement and scientific objectivity to help our team learn new methods of reliability and consistency in our clinical processes.

Several studies show that engaging clinicians in leadership and management roles is correlated with important drivers of organizational performance. (16-19) It is time to improve the "business model" of health care leadership by integrating it with the "clinical model" of leadership that is so familiar to physicians: first, making sure that our patients are free from harm; second, implementing evidence-based medicine for diagnosis and treatment; and third, listening to the unique needs and concerns of our patients within an atmosphere of teamwork. Organizations that embrace this approach can look at changes in financial and clinical metrics to quantify the impact of this unifying concept of health care leadership.

We urge all of our physician colleagues to imagine themselves not just as "providers of care" but also as clinical leaders, whether working at the bedside or in the executive suite. Each of us can contribute significantly in the years ahead to creating a safer, more reliable and responsive health system.

Let's acknowledge that we all share common priorities and leadership principles regardless of our roles in the health care system. With economic and societal pressures for change increasing, we can apply the three core professional principles outlined above to provide the leadership necessary to shape a more reliable, efficient, and responsive health care system.


(1.) How SK, Shih A, Lau J, Schoen C. Public Views on U.S. Health System Organization: A Call for New Directions. Commonwealth Fund; August 2008.

(2.) Weber, D. Unethical Business Practices in US Health Care Alarm Physician Leaders. The Physician Executive; 2005; 31(2): 6--11.

(3.) The Commonwealth Fund Commission on a High Performance Health System. Why Not the Best? Results from a National Scorecard on U.S. Health System Performance; 2006.

(4.) Christensen CM, Grossman JH, Hwang, J. The Innovator's Prescription: A Disruptive Solution for Health Care. New York, NY McGraw-Hill; 2009:79.

(5.) Wieck KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, CA: Jossey-Bass; 2001.

(6.) Cook RI, Woods DD. Operating at the Sharp End: The Complexity of Human Error. In Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Erlbaum and Associates; 1994:255-310.

(7.) Reason J. Managing the Risk of Organizational Accidents. Hampshire, UK: Ashgate Publishing; 1997.

(8.) Nance J Why Hospitals Should Fly: The Ultimate Flight Plan in Patient Safety and Quality Care: Bozeman, MT: Second River Healthcare Press; 2008.

(9.) HealthLeaders survey. February 2009, p.23.

(10.) Kohn LT, Corrigan JM. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 2000.

(11.) Hall RE, Fragola JR, Wreathall J. Post Event Human Decision Errors: Operator Action Tree/Time Reliability Correlation. Washington DC: U.S. Nuclear Regulatory Commission; 1982.

(12.) Porter ME, Teisberg EO. "How Physicians Can Change the Future of Health Care." JAMA; 2007; 297(10):1106.

(13.) Cabana MD et al, "Why Don't Physicians Follow Clinical Practice Guidelines?" JAMA; 1999; 282:1458-1465.

(14.) Collins J. Good to Great. New York, NY: HarperCollins Publishing; 2001:74-78.

(15.) Kearns DB, Summerside PR, Woods MS. Redefining the Physician Executive. The Physician Executive; 2009: Jan/Feb p. 37.

(16.) Shortell S. "An empirical assessment of high performing medical groups: results from a national study." Medical Care Research and Review; 2005; 62(4):407-34.

(17.) Casalino L. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA; 2003;289(4): 434-41.

(18.) Managing Change and Role Enactment in the Professional Organisation, National Co-ordinating Centre for NHS Service Delivery and Organisation; 2006.

(19.) Mountford J, Webb C. When clinicians lead. The McKinsey Quarterly, Health Care; February 2009.

By Barry R. Silbaugh, MD, MS, FACPE, and Harry L. Leider, MD, MBA, FACPE

Barry R. Silbaugh MD, MS, FACPE



Harry L. Leider MD, MBA, FACPE

ACPE President

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Title Annotation:ACPE White Paper
Author:Silbaugh, Barry R.; Leider, Harry L.
Publication:Physician Executive
Geographic Code:1USA
Date:Sep 1, 2009
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