Washington Gov. Chris Gregoire has announced the adoption of a resolution by three major state medical associations to help ensure that patients are treated fairly by the healthcare system. The Washington State Hospital Association, Washington State Medical Association and the Washington Ambulatory Surgery Center Association have all adopted the voluntary agreement to not ask patients to pay for care related to serious medical errors. The agreement applies to 28 specific "adverse events."
Staff training and customer service initiatives can go a long way toward creating an exceptional patient experience, but there's no one-size-fits-all solution. Patient segments differ. Thus, it is important to know what each segment wants and what is important to them.
Most practices will have a mixture of the following types of patients:
1. Comfort seekers want to feel welcomed and comforted by staff and desire significant contact with family and friends. They value convenient scheduling and delay notifications. This group tends to be younger, with children and lower incomes.
2. Amenity seekers have higher incomes and are willing to pay for comfort. Strongly influenced by hospital or provider reputation, they are more likely to ask their physician for a referral to a particular hospital or specialist.
3. Control seekers are interested in efficiency and information. They are most willing to challenge a doctor's recommendation. This segment has less interest in entertainment and Internet access, and they often have lower incomes.
4. Just the basics patients are most concerned about location and convenience. They have less frequent and less intense provider encounters, and they are most likely to have high deductible health plans.
5. Physician-reliant patients are heavily dependent on physician recommendations. Some members of this segment delay a hospital or specialist visit after receiving their doctor's diagnosis. This group is the least likely to be influenced by patient experience factors.
For all segments, the most valued element of experience is being kept informed.
Launching a new clinic or private practice must give partners and practitioners a tremendous sense of accomplishment--especially when the organization's mission is to provide for the medically underserved. With this in mind, I wonder what it must feel like to be U.S. Navy Commander Dan Cornwell, FACHE. As part of the Embedded Provincial Reconstruction Team in Camp Fallujah, Iraq, Cornwell has worked to rebuild and increase the capacity of the Iraqi healthcare system.
On the day I spoke with him, Cornwell had just returned from the grand opening of a new public health clinic in Fallujah--a place of danger and turmoil as a major battleground just a matter of months ago. "It was just a banner day," he said. "We treated over 800 people--a lot of women and children." This was the third such opening Cornwell has attended in the past year, since he began his partnership with local physicians, Iraq's Ministry of Health, and other governments.
To sum up Cornwell's mission: He provides true healthcare leadership where none previously existed. In fact, when he first set foot in Fallujah, the city lacked the basic healthcare necessities. There wasn't consistent trash removal, power supply, sewage system, and clean water. Imagine treating patients at the 200-bed Fallujah Medical Center and not knowing when or whether you'd have electricity.
Through it all, due to the credit of the local physician leaders, the hospital never shut down. It typically has 125 inpatients and treats about 1,000 outpatients a day. The medical center's staff performs about 1,000 surgical procedures per month and delivers about 700 babies. On top of all this, the training facility produces about 30 physicians per year. Cornwell says one significant change is that there are fewer trauma cases in the ED and more primary care patients.
"So it's starting to look more like a U.S. hospital," he joked.
I asked him how he benchmarked the rebuilding efforts over time, and he laughed. "A lot of things we just don't have, so it's an easy benchmark to measure," he said. For instance, the city didn't have an emergency medical system, so Cornwell coordinated with the Iraqi health system to get ambulances and technicians.
Today, many of the basic necessities are in place to maintain the healthcare system in Fallujah. It now has backup generators, clean water, and a security enclosure. In fact, the current medical center will be turned into a women and children's hospital when a brand new 300-bed facility is completed later this year. Medical professionals who fled the city are returning. Cornwell believes that soon the system will be self-sufficient.
"We've almost transitioned to them," says Cornwell. "We've taken care of the biggest show stoppers--EMS, power, renovations, expanding the OR, and opening new clinics. Today was a great example. We open this clinic to a community of about 40,000. We're gaining trust between the health system and the people, and it's a great feeling."
In the end, Cornwell's story is an example of the commonality of human need. It doesn't matter if you live in Tulsa or Fallujah when it comes to healthcare. People want access to quality care in a safe environment from people they can trust. We often knock the U.S. healthcare system's shortcomings--and it surely has them--but there is so much that we take for granted. In Fallujah, where citizens finally have access to physicians and soon a state-of-the-art medical center, there is a new sense of normalcy and security that comes with a functioning healthcare system.
Commander Cornwell said this was a once-in-a-lifetime experience that on an emotional level was life changing. I suspect that he's not the only one to feel this way.
It seems that conflict is the fastest-growing product line in contemporary healthcare. Medical staff leaders must become comfortable with navigating these potentially treacherous waters. Here, we offer practical approaches and strategies designed to help medical staff leaders understand and begin to grapple with the real day-to-day issues encountered.
Beginning with the end in mind, here are some snapshots of what successful outcomes might look like:
A formalized medical leadership academy with defined curriculum supported by physicians and the hospital for the teaching, training and development of physician leaders
An explicit compact between the physician and hospitals defining mutual expectations and behaviors
Groups able to work and play together with trust growing from structured access
A shared vision of mutual success and the communication skills necessary to engage in vital conversations about present and future states.
Compare this to the current reality in many organizations. What often exists is unmanaged conflict, poor communication skills, lack of trust and an absence of respect. It is a very real observation that conflict in healthcare is a growth industry.
The Greeley Company has developed a ten step approach to improving physician and hospital relations. A central theme underlying this proactive approach is communication on multiple levels, in varied forums and as part of an ongoing commitment to leave things better than we find them.
Step 1: Acknowledge physicians are customers, partners, suppliers and competitors. The first step is to acknowledge that physicians are simultaneously customers, partners, suppliers and competitors of hospitals. This is clearly a "get over it" moment for most of management. In order to make progress in this new environment, the change must first be acknowledged, discussed and understood. Only then can progression occur.
The ability to manage conflict is a necessary skill to approach this new paradigm. Physician and hospital leaders need to learn to distinguish which problems can be solved and those which are unsolvable and require training in Polarity ManagementT to handle. The ability to manage the following polarities is critical to success:
Physicians are both customers and suppliers
Physicians are both partners to be worked with in a collaborative fashion but are simultaneously competitors for shrinking healthcare dollars
Physicians are both independent practitioners yet mutually accountable to each other for the quality of care rendered by individuals granted privileges at the hospital
Step 2: Heal the past. To move forward and succeed, the past must be healed. To achieve this, several things must occur:
Identify the perceived injuries from the past
Agree to "no playing old tapes"
Work through the polarity of impact and intent.
As will be seen in the next steps, tools for success include multi-channel communication, development of physician leadership competencies, negotiation skills, strategic thinking and specialized tools such as Polarity ManagementT.
Step 3: Create a shared vision of mutual success. Physicians and hospitals must create a shared vision for mutual success. Efforts to align physicians and hospitals toward a common purpose often prove difficult. These groups have different beliefs about what is important, posses conflicting perspectives on who they are and often perceive each other as distinct or threatening.
The first necessity is the development of a strategic plan for the medical staff. Virtually every hospital with whom we have worked has a strategic plan; conversely, very few physician medical staffs do. Strategic planning is a disciplined effort to produce fundamental decisions and actions that shape and guide what an organization or group is, what it does and why. The Medical Executive Committee should charter the development of:
A mission statement which is a precise statement of purpose. The Greeley Company teaches that the fundamental purpose of the medical staff is to monitor and improve the quality of care that is primarily dependent upon the performance of individuals granted privileges.
A vision statement which answers what would it look like if the medical staff hit a home run fulfilling this mission. The Greeley answer to that is a truly effective medical staff form and function; indeed, much of our work with physicians and hospitals is how to achieve that effectiveness.
The second necessity is to acknowledge that the old medical staff development plan based on needs, demographics and physician age is outdated and inadequate to deal with today's increasingly complex environment. There needs to be multiple joint physician-hospital strategies:
An organized medical staff strategy that includes a physician-hospital compact, formal leadership development, building social capital and increasing communication.
Alignment strategies by specialty which can include employment, exclusive contracts, medical directorship, joint ventures, recruitment support and on-call compensation. In short, not one size fits all. Flexibility is paramount and not all physicians get treated the same
Recruitment and retention strategies based on physician satisfaction surveys, recruitment support, physician liaison, practice support, branding, operations councils, contracting strategies and no volume/low volume alignment. Competition and collaboration strategies which might include conflict of interest policies, joint ventures, facility leasing, economic credentialing issues and managed care contracting.
Step 4: Develop mutual expectations for physicians and the hospital: The physician-hospital compact. A compact, very simply, is an agreement or covenant between two or more parties. The covenant is a written agreement between the parties for the performance of some action. The development of a compact, a written covenant, between the medical staff and the hospital can be a powerful tool to discuss, develop and codify mutual expectations of each other.
A powerful starting point is to look at the respective mission statements of the medical staff and the hospital. The medical staff mission statement would include insuring the quality of care of individuals granted privileges and being mutually accountable to each other for that care. The hospital mission statement probably includes language outlining how it provides patient-centered quality care to the community or region it serves. A joint starting point then might be:
"There is a mutual interest in providing better and expanding clinical care and programs to our patients and our communities."
Using this as a starting point, the physicians and hospitals can codify what expectations might be addressed in the compact, including:
Expectations of each other, including what physicians would expect from the hospital to provide quality staffing and timely, excellent support services. Also, what the hospital would expect from physicians to be effective in holding each other accountable for care delivered by individuals granted privileges
Expectations of mutually beneficial clinical and business ventures that would be explored on a right of first refusal basis
Expectations that fair and just processes would be developed to handle conflict, disagreement and violations of the compact
The use of a compact is an effective tool for the alignment and advancement of diverse groups in their mutual interest to provide better and expanding clinical care to patients and communities.
Editor's note: In an upcoming issue of HealthLeaders Media PhysicianLeaders, we will continue with Part 2 of the 10 Steps to successful physician-hospital relations.
William K. Cors, MD, MMM, FACPE, is Vice President of Medical Staff Services for The Greeley Company, A Division of HCPro, Inc., in Marblehead, Massachusetts.
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