This article appears in the July 2012 issue of HealthLeaders magazine.
Today, many hospital organizations are teeming with teams, forming physician groups to make decisions about bringing in new doctors, provide clinical care, and make recommendations about administrative planning:
In Maryland, a longtime CMO retires and the opening creates an opportunity to revisit the entire structure of physician involvement for a health system.
In Texas, a physician team lays the groundwork for how a new hospital is built.
In Wisconsin, a large medical group looks inside itself to revamp its physician team to coexist with a larger health system.
Developing teams
As various health systems work to put physician teams together, the organizations often abandon old models. They are looking to forge relationships bound by teamwork, cohesiveness, and coordination as never before. They also want team members who appreciate the fact that a hospital must operate as a business.
Hospitals that acquire physician groups need precise planning to integrate these new medical teams. "We recruit physicians who share our philosophy," says Paul Colavita, president of the Carolinas HealthCare System's Sanger Heart & Vascular Institute, which has more than 90 physicians and 24 locations in North
and South Carolina. CHS, based in Charlotte, N.C., has 6,300 beds in locations in both states. As Colavita evaluates physicians for his team, first and foremost "they must be team players to function well in our organization," he says. Sanger relies on references from the physician's instructors, partners, and colleagues. Putting patients first is the top priority. "The decision-making is evidence-based and appropriate," he adds.
Under the old medical staff model, physicians provided clinical care only within the appropriate silo in a top-down structure that walled off communication. Information might move up or down the ladder, but rarely from silo to silo, which impedes real discoveries and breakthroughs in advancing care and identifying efficiencies that can be shared.
Now hospitals are expanding their physician teams and revamping their leadership structures, establishing specialized committees to oversee various jobs and undertake new missions. And some are going further, establishing academies to cultivate physician leaders for various teams.
Developing leadership
Such leadership cultivation is what the Iowa Health System has done in preparation for a planned accountable care organization, says Bill Leaver, president and CEO of the 1,291-bed system based in Des Moines. Earlier this year, the system joined with Wellmark Blue Cross and Blue Shield of Iowa to form an ACO, in hopes of reducing hospital readmissions.
To prepare for the ACO, Leaver says Iowa Health System had little choice but to improve its physician team, concentrating on developing physician leaders, now and for the future. Two years ago, the Iowa Health System created a physician leadership academy, an intensive graduate-level course of study that focuses on individual development and advanced leadership training with an emphasis on strategic skills, quality innovations, and information technology. Physicians selected for the leadership academy participate in a confidential assessment to identify their strengths and weaknesses, as well as to pinpoint the knowledge and skills needed to be effective leaders.
"Developing our primary care base is really our overall strategy," says Leaver. "We felt we were more of a hospital-centric organization and needed a more integrated delivery of care, to be physician- and patient-centered. We won't be able to have physician buy-in to the [ACO] model unless we create physician leaders now." More than 30 graduates currently are being considered for leadership positions in the organization, he says.
Developing balance
As Barry P. Ronan, president and CEO of the 275-bed Western Maryland Health System in Cumberland, examines the current physician landscape and the needs of his facility, he says the organization works to maintain a balance among hospitalists, specialists, and subspecialists. "As more and more attending physicians give up their hospital inpatient privileges to focus on their office practices exclusively, we add additional hospitalists or nurse practitioners," Ronan says. "We also continue to recruit specialists and subspecialists in the community in order to complement our existing physicians and to support our extensive program requirements."
Hospitals must always look at costs when they are recruiting individuals for teams. It is estimated that a physician search can cost as much as $50,000. Another $20,000 may be spent on signing bonuses and other incentives. But the right physician is worth the recruiting investment, bringing in potentially millions of dollars for a hospital depending on the specialty—and adding that "perfect fit" so essential to a hospital's goals.
When assembling a physician team, Christine Griger, MD, president of the Affinity Medical Group, part of the three-hospital Affinity Health System based in Menasha, Wis., says her group is exploring different ways to improve physician relationships within the larger health system, especially as it forms teams for medical home care.
"We have people knocking on our door to get in," Griger says of physicians seeking the security of hospital employment within the Affinity Health System. "There are physicians who have been independent and in smaller groups, wanting that security and stability of a healthcare system. But we need them to function not just as a physician, but as a businessperson, too," she says. Affinity Medical Group includes 265 physicians and advanced practice providers and 26 clinics in northeastern Wisconsin.
With Affinity's unified medical staff, any member of the medical group can serve as a department chair or head of quality. Still, as Affinity executives examined its governance structure, it sought more physicians in leadership roles, says Griger.
"We need more physician leadership in operational issues, for quality and patient satisfaction and productivity," she says. "We are developing a title of a regional VP for physicians, who will be involved in physician leadership primarily in an administrative way," she says.
The health system enlisted "all types of team development and collaboration" across the sites as it initiated case-management changes and improvements in staff to stay on track with patient-engagement protocols, Griger says.
Developing accountability
Colavita of the Sanger Heart & Vascular Institute says his health system chooses team members who are responsible not only for various aspects of care, but also for documentation of specific metrics for procedures during a patient's stay—and sometimes even after a patient is discharged. A Carolinas HealthCare System quality committee reviews the patient data to improve patient outcomes, Colavita says.
The Sanger Heart & Vascular Institute stepped up its team concept in recent years after a large cardiology practice joined it. Regional and subspecialty medical directors are charged with overseeing operations divided into various aspects of care, such as cardiovascular surgery, Colavita says. Each physician group can be empowered with clinical decision-making and hire doctors. "We actually have a ‘delegation of authority' document," he explains. "This document defines who can recommend and/or approve a decision. The doctors can decide to hire another physician; the executive committee may decide to open another office."
The institute's executive committee is composed of members from the CHS administration, Sanger Heart & Vascular Institute, and Carolinas Physician Network. The officials are the SHVI president; the chair of the department of cardiovascular and thoracic surgery; the regional medical director; three CHS executive vice presidents; a CHS hospital president; the SHVI executive director; the CHS chief medical director; the Carolinas Physician Network senior vice president; and the Sanger metro (subspecialty) committee chair.
"What's necessary is a common culture, and an understanding where different physician groups are coming from," Colavita adds. "Each physician has a stake in this. There is nothing to be said about arguing with each other, but working together and doing a better job."
The physician teams have led to creation of CHS' Chest Pain Network, a network of nine area hospital and local EMS agencies that streamlines the transfer and treatment of heart attack patients. It also allows patients with less critical conditions to be appropriately cared for closer to home.
The system has also launched a Heart Success program, with a multidisciplinary team including an advanced care practitioner, patient navigator, dietitian, social worker, and pharmacist. This initiative has resulted in improved clinical outcomes, Colavita says. The program focuses on educating heart failure patients to better manage their disease and return to the care of their primary care physicians and cardiologists. The idea is to prevent readmissions and enhance the patients' quality of life.
Colavita credits this team concept to improvements in CHS' readmission rates. From the third quarter of 2011 to the first quarter of 2012, the 30-day readmission rates at CHS' Carolinas Medical Center decreased from 19.7% to 11.4%, according to the hospital.
Developing a council
Ronan saw an opportunity to do things differently by restructuring Western Maryland's physician team after his veteran CMO retired from the position and became a hospitalist at the facility. Ronan thought about the long list of challenges the system faced, even though it had just opened a new facility in late 2009.
Ronan knew that, in earlier years, the hospital would have replaced the CMO quickly to ensure continuity. But Ronan and his staff realized the landscape of healthcare was transforming so much that it was no time for a quick fix.
Following guidance from consultants, Ronan asked the president's six-member quality council to identify and bring on board six additional physicians to work directly with the C-suite. Besides participating in the search for a new CMO, the larger purpose was to help determine the direction of the hospital system.
These physicians were official and unofficial leaders. "This wasn't our medical executive committee; these were movers and shakers in the hospital. They included independent practitioners, as well as hospitalists," he says.
"Nothing at the hospital gets done that the medical staff doesn't agree with," Ronan says. "The medical staff feels very involved in the decision-making at the clinical level, but it's also important they feel involved in decision-making at the management level."
The 12 physicians on the president's council in turn led various subcommittees composed of three physicians each, focusing on an array of specific subjects: examining documentation and coding procedures; reducing readmissions and revamping the hospital's service lines; opening a new wound care center and considering a heart failure clinic; and improving programs to combat pneumonia. The hospital also relied on this subcommittee structure to look into ways to increase home healthcare, with the idea of reducing utilization. Another issue the subcommittee investigated involved evaluating community needs so patients would be less likely to seek hospital care in distant cities like Baltimore and Washington, D.C.
Developing cooperation
Cooperative physician teams were important for developing the hospital's heart failure clinic, Ronan says. At least 50 patients were enrolled in the clinic, with many referrals by hospitalists and providers in the hospital's observation unit. Multidisciplinary teams "identified several medication mismatches from discharge instructions and have intervened to make appropriate adjustments in medications," he says. Patients also have been screened for sleep apnea and referred for sleep studies, or to nephrology and home care when appropriate.
The hospital has increased its collaboration with "primary care physicians, and our focus is on disease management by setting personal goals," Ronan says. "We also help to achieve the goals through formalized individual and group teaching with collaboration with dieticians and pharmacy staff."
Hospital leadership consistently talks with primary care physicians about the potential of the heart failure clinic. "The chief medical officer is assisting by ‘talking up' the heart failure clinic to medical staff," Ronan says. "He is emphasizing that enrolling patients in the clinic will free some of their office time that is spent managing complex patients."
Developing a culture
When putting together a physician team, hospital leaders have to determine not only where the pieces of the puzzle fit, but also how to change the culture of the organization to conform with the new puzzle's shape. Nearly all medical systems employ medical directorship teams to evaluate quality and patient safety in their organizations. Others are broadening the roles of physician staff to further evaluate hospital needs, whether it's hiring a new administrator or defining what service lines to add for anticipated patient needs.
Hospital leaders who are forming and reforming physician teams examine their patient demographics to determine the demand for certain specialties—such as cardiologists, oncologists, and orthopedic surgeons, whether employed or independent—as well as the needs for its primary care base.
Developing a primary care base
As health systems consider accountable care organizations, development of teams with primary care at their base is crucial for a hospital, says Jim Stone, who is president of the Medicus Firm, a physician recruitment company with offices in Atlanta and Dallas, and serves as president-elect of the board of directors for the National Association of Physician Recruiters.
"I think with the concept of the ACOs on the horizon, and basically getting into a capitation type environment, the key component for a health system will be to manage care for that patient population," says Stone. "To do that, you need to control physician behavior, and you can't do that without having the influence of a primary care physician quarterbacking" overall patient care, he adds.
But hospitals must rely on a population foundation to develop their physician teams, and that rests with demographics, says Griger. When a hospital system balances deciding whether to get hospitalists or subspecialists in the most cost-effective manner, much of it is related to demographics, which must be evaluated closely.
"We have hospitalists, intensivists, invasive cardiologists, and cardiac surgeons here because there is a need and there is the population to support those services," she says. "We don't have a cardiac transplant service because there aren't enough patients here who need that service, either to support it economically or to maintain the level of technical expertise needed to do that kind of work."
Most hospitals are reporting an increasing need for psychiatrists and neurologists, accounting for 15%–20% of placements, according to Stone. Primary care placements remain the highest percentage of all—34%—with surgical specialties next at 20%.
Developing together
Performance improvement teams are an integral part of how hospitals are incorporating collaboration for the clinical future. Some hospital teams look into how they can better handle specific medical conditions, such as congestive heart failure or diabetes. Or, they focus on particular processes within their facility, such as a specialized physician team on readmissions.
The 187-licensed-bed Portneuf Medical Center, in Pocatello, Idaho, also has what it calls a physician roundtable that advises and is involved in day-to-day administrative and clinical concerns. In one instance, the group acted as an intermediary regarding an issue brought up by an emergency department physician about what he termed a "broken referral process" from critical-access hospitals, where a physician was not following up with referral sources in a timely manner. This operational issue was discussed by the roundtable, and ultimately addressed by the physician's practice manager, says Norman Stephens, president and CEO.
Sometimes, the results of physician team collaborations set the stage for new opportunities. For instance, Seton Medical Center Harker Heights has established a roundtable that CEO Matt Maxfield, FACHE, says was especially needed to coordinate independent physician groups when the hospital system built a new $100 million, 83-staffed-bed hospital in the central Texas area of Harker Heights, which held a grand opening last month. The physician advisory group was pivotal for reviewing and making suggestions for the new hospital, developing medical staff bylaws, and approving a physician recruitment plan.
The Seton Healthcare Family, which includes five medical centers and is a member of Ascension Health, is affiliated with the University of Texas Southwestern Medical Center in Dallas. Seton had a joint venture with LHP Hospital Group Inc. to build the new hospital. The joint venture's governing board includes representatives from LHP—a Plano, Texas–based company that owns, operates, and manages acute care hospitals through joint ventures—and Seton, as well as a board of trustees composed of physicians and community members.
The physician roundtable meets monthly to discuss any areas of concern involving physicians and administrative staff. "You have a representative of each house of medicine. It was truly by design that we were trying to get the representation of all different departments and primary care representation as well," Maxfield says. The multispecialty groups included physicians from Austin Heart and King's Daughters Clinic, medical groups in Texas whose doctors were closely involved in planning for the new hospital. The groups focused on service and culture, as well as clinical development and operational issues.
"It's a team collaborative effort, with complete transparency over the last two years," says Charles R. Day, MD, chief of staff at Seton Medical Center Harker Heights. "It's fair to say the local physician team has been quickly integrated into the management culture. The organizational structure encouraged physicians, who played a role in building this hospital and had a say about moving the dirt to what kind of MRIs to buy."
Seton Medical Center Harker Heights set the stage for collaboration before ground broke, and it plans to sustain that culture now that doors are opening. "We have had a physician team through the development of this hospital, the design, and my hope that it continues that way," says Maxfield.
This article appears in the July 2012 issue of HealthLeaders magazine.
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Joe Cantlupe is a senior editor with HealthLeaders Media Online.
