Chief medical officers have an extremely tough job these days. No longer are they mere figureheads, owing their position largely to being noncontroversial and easy to work with.
Instead, they are expected to bridge the gap between the clinical and the financial. And that's impossible without the backing of a strong CEO. No two senior executives' fates are more closely tied together.
Mark Kestner MD, now a consultant with Guidon Performance Solutions, has been CMO at many stops over the years, and he bears the scars. Included among them was a stint as CMO at Alegent Health in Omaha, where an attempt to standardize clinical work patterns and establish operational efficiency ended with a physician revolt and the resignation of both the CEO and CMO (Kestner).
Alegent, given the predominance of fee-for-service reimbursement, was ahead of its time, Kestner says. Now that reimbursement is truly being shifted toward performance measures. And now that hospitals are being penalized for readmissions, the message is a little easier to deliver, he says. Still, the transition is slow, because physicians don't often recognize that the change is permanent.
"In most communities, the hospital is the common space for people to establish their relationships. And if there was a governance of physician practices, it was generally generated outside a hospital. Does that structure serve us going into the future?"
In short, he says, no.
"If you look at an ACO model, you are trying to avoid hospitalization, but there's no common point for physicians to congregate to have some organizational structure. Yet the hospital is de facto the entity where physicians participate in a legislative process. If your government isn't going to serve you well into the future, then you better have a backup plan."
He says he's learned over the years to find a way to respect that traditional legislative body, but to also bring in other allied medical providers to establish standards of care in a multidisciplinary fashion.
"We can set up a neutral ‘Switzerland' which aspires to standardized care, order sets, and competencies, which will report to a regional clinical council of some sort which can be made up of nurses, leadership, the CMO and medical staff leadership," he says.
"That allows you to continue to respect the organized medical staff for hospital-based operations because most boards have delegated organizing quality to the medical staff. You have to respect that legacy entity."
Beyond that, for most community hospitals, Kestner says, the CMO has to be in charge of evidence-based medicine. The CEO can't be in this role, he says, advocating for a clear separation of powers. Rather, the CMO needs to help facilitate the development of these muitidisciplinary teams, clearing the CEO to focus on business models.
"I stay clear of business models. The best thing for CMOs is to always focus on the care delivery model and the evidence. That's supposed to be our expertise," he says. "If you aspire to that, people will respect you, however, that doesn't mean you won't be victim of politics."
CMOs can't be concerned with that, however. If you level the playing field among your nursing and pharmacy peers and ensure that physicians are part of a multidisciplinary team, that helps you weather political storms, he says.
If nursing and other leadership peers are behind the strategy toward standardizing care, then that structure can help break up some of the political storms that come along with the job. But he also counsels CMOs to know what it's like to try to do the job from other members' perspectives.
"What carries a lot of weight is knowing what the challenges are for the frontline staff. I need to be trained on it to have a constructive dialog with people," he says.
For example, one of his clients is in the middle of an Epic IT conversion and he's undertaking 45 hours of training on the system because the implementation is encountering more-than-anticipated challenges.
"That carries a lot of political weight too," he says.
Although Kestner, trained as a trauma and critical care surgeon, still practices on nights and weekends, he says the perception persists among other physicians that the CMO has permanently traded in his scalpel for a suit.
"When you stop practicing medicine, you have to build your credibility in different ways," he says, speaking of taking on Epic training, for example.
A CMO's job is fraught with political peril, because "providers have never been easily corralled into doing things a certain way, and they're powerful people."
The first thing the CEO should recognize is that they're asking the CMO to do a huge job and should make sure they have the resources.
"At Alegent, I had them," he says. "I had 150 employees who reported to me, and when I wanted to do transformational work, I could focus the workforce on accomplishing the task."The CEO also needs to make sure the organization is organized appropriately to address the future changes that need to occur, he says, and if not, re-delegate to accomplish those tasks.
Because everything in hospital databases has historically been financially based, that's where people most often start when they think of care standardization and resource utilization, but getting rid of the variance isn't the solution, he says.
Instead, you have to be able to provide a framework under which everyone agrees to how they should practice. Only then will you be able to start to address costs.
"I was working with a system and wanted to know how to manage their electronic medical records, so they went to see Geisinger (Health System, in Danville, Pa.)," he says. But likely, that was a mistake because most hospitals have nothing in common with Geisinger's organizational structure as an all employed-physician clinic model.
"Their governance and decision-making is altogether different and docs own their decisions because they have a vested interest," he says. "In a community-based system, most leaders haven't gotten over the idea that physicians are your customer. They're not. If you haven't bridged that gap, your solutions won't come from the Geisingers and Mayos of the world."
The real value of CMO is in determining where to be four to five years for now and creating the vision for clinicians to hope and aspire to, he says.
"The CEO can't provide a clinical vision any better than I can provide a financial or acquisition vision," he says. "The CMO has to be the mouthpiece for why care standardization is desirable and provide a vision of where we want to be a year or three years from now, extending care beyond the four walls of the hospital."
If they can do that, physicians will recognize them for something other than being a suit.
And one last piece of advice for both the CMO and CEO: "You won't get there without each other."
Philip Betbeze is the senior leadership editor at HealthLeaders.