Give Your Physicians an Incentive to Lead

Physicians don't respect authority.

Now before you fire up your email eviscerations and your Twitter tirades over that statement, let me finish. Of course, this is not always true. And sometimes when physicians exhibit disrespect, they have good reason.

Authority suggests being dictated to. Leadership suggests collaboration.

It's been said that physicians will adapt to changes in practice if they get data proving it's the best move for the patient. Banner Health, a 14-hospital system based in Phoenix, is testing that assumption.

Before ACOs, bundled payments and the continuum of care became the coin of the realm of healthcare, leaders at hospitals and health systems were often seen by physicians as following their own interests (and to be fair, vice versa).

That is, the interests of the hospital or health system, which often didn't coincide with the interests of the physicians who were being dictated to. Thus, they did not follow. But smart organizations are changing the way they seek to lead physicians to new ways of practicing medicine in which the patient's well being is the key.

Thus the overused buzzword 'physician alignment.' But boiled down, the key might just be that they're injecting physicians into the leadership structure—something hospitals and health systems have had trouble doing in the past.

John Hensing, MD, is executive vice president and chief medical officer at Banner. I interviewed him as part of this month's leadership story in the magazine, "Time to Trash Your Org Chart?"  but I didn't have enough room to use his interview in the article. That's a shame, because he and his colleagues are working on some innovative stuff from a leadership standpoint, evidenced by the fact that Banner is making a big effort to include physicians at the top of the leadership food chain. You can see why it just snagged one of HealthLeaders Media's Top Leadership Team Awards.

"Where we're going will require an even higher level of clinical performance, financial discipline and sustainability," he says. "We're moving from a services-based to outcomes-based industry. That means clinical leaders will be essential."

Within the past five years, Banner has grown its CMO base more than eightfold, from three to about 20, and most of them are facilities-based, meaning they (presumably) understand the problems and unique situations facing practicing physicians at particular hospitals and physician practices. Edicts don't come down from on high anymore, rather, the local CMO works with physicians to tailor solutions in an environment where fee-for-service will become less common and reimbursement will be at risk, says Hensing.

The individual hospitals can serve as demonstration projects, if you will. Every fourth Wednesday, Hensing convenes a meeting in which the he and the CMOs who report to him spend four to five hours discussing initiatives and performance targets and to review overall strategy.

"We are fortunate to have a single board of directors overseeing fiduciary and quality accountability for every operating unit," he says. "That includes not only the hospitals, but the surgical centers and medical groups. All of our entities report clinical and financial performance up to a single board. That allows us to have a very important tool for standardization. Second, we have a single senior management team that reports to that board. All clinical leaders report to me. It's an operating company model with direct reporting to a central leader. That's uncommon in the nonprofit world."

In terms of establishing standards, physicians aren't dictated to. Instead, Banner convenes various leadership groups which determine the ways to achieve quality of care and outcomes targets -- for instance, adopting standardized antibiotic administration -- based on physician-generated solutions, of which there are dozens.

In fact, Banner currently uses a group of physicians and other clinicians who meet in a series of clinical consensus groups to establish standards in 12 different areas.

"It's really designed to adopt clinical rather than operational standards," he says. "It's not designed to grow business like a typical service line."

Why? Well, for starters, no one's exactly sure how patient care standards and outcomes measures will evolve over time.

"If we're all doing it the same way, we're more able to tweak it later," he says. "We believe if we're all doing it the same, we're a lot more likely to be able to improve than if we're all thinking we're doing it the best."

Banner's annual strategic initiative process measures clinical performance, and the publicly reported ones, such as pneumonia, asthma, and surgical care are essential, he says. They're measured on a scorecard that's reported transparently throughout the organization.

Hensing says a key change in the attitude physicians take on the initiatives is reflected by the board's trust in site-specific CMOs and chief nursing officer.

"The key leaders at our hospitals are the CMOs and the CNO," he says. "They are partners in clinical performance at the facility and are key in their ability to work together and to prioritize a collaboration. Nursing is at least as important."

Though Hensing doesn't think Banner has exactly figured out the challenge of motivating practice changes in physicians, it has changed the often contentious nature of the relationships between physicians and "corporate." When physicians think of autonomy as being able to do what they think is most effective for the patient, they're on the wrong track, he says. Decisions have to be backed up with clinical data.

"Acquiring clinical knowledge does not qualify you to provide better care," he says. "It's an essential but insufficient feature."

At this point, Banner is in the process of analyzing cost, processes, and clinical processes. "Do we have length-of-stay or cost variation that allows us to determine our complication rate? Our mortality, our morbidity? If there's high variation we want to go after that."

Banner is working hard on standardizing colon surgery now because it has identified that high levels of variation exist between hospitals and even individual surgeons in the system.

"This is not a fast process, it will take several months to assess data, make recommendations, and get to design for implementation," Hensing says.

So I think I'm correct in making the statement that physicians don't respect authority. In the past, as a group, they resisted being told how to better practice their craft not only by administrators without the MD title, but they also resisted those who did have it.

The assumption was that these authority figures could no longer be trusted because they'd gone to the "other side." That is (or was) that the physician in the leadership spot was representing the hospital's best interests on standardization of practice or medical implants or devices, because it favored the hospital's business activities, not necessarily because it had anything to do with improving patient care.

In many cases, as Hensing and his colleagues show, we've come a long way.