Healthcare leaders need to reinvent the C-suite and establish a new set of leadership skills to help them address the challenging nature of hospital-physician competition and collaboration. These new management core competencies or the "seven Cs" are:
- Embracing change
- Seeking collaboration
- Increasing communication
- Handling competition
- Managing conflict
- Influencing culture
- Cultivating influence
Two weeks ago, we explored the first three core competencies of the seven Cs. This week, we continue with competencies four through seven.
Handling competition
Physician-hospital competition is a nationwide issue that affects how hospitals and physicians relate to one another. Without a clear basis on which to proceed, your organization will flounder and shudder in the face of unmanaged competition. The following are strategies and tools to employ in this potentially volatile arena.
For instance, a solid conflict-of-interest policy that encourages full disclosure goes a long way in helping medical staffs and hospitals achieve the goal of figuring out how to collaborate and compete. A good starting point is to understand the myriad ways in which conflicts of interest can occur. Some of these include:
Physician-physician conflict:
- Competitors performing peer review
- Credentialing/privileging disputes
Physician-hospital conflict:
- Leadership position at a competing hospital
- Competing ambulatory services
- Physicians in joint ventures with other hospitals
- Physicians who are loyal to other hospital staffs
- Medical staff leadership roles (e.g., vice president of medical affairs and paid chairs)
- Physicians as governing board members
Physician group conflict:
- Employed physicians
- Exclusive contracts
- Medical directors
- CEO's "kitchen cabinet"
- Joint-venture partners
- Contracted services
Physician's personal conflict:
- Personal relationships
- Religious issues
- Families/relatives with related or competitive interests
- Physicians involved in competing or similar research
- Ethnicity issues
- Ownership or interests in device manufacturers
In recent years, hospitals have developed various strategies for handling competition from physicians. Some have pursued joint ventures for ambulatory services or opted to build service lines to try to force competitors out of the marketplace. Hospitals that pursue these options often deny medical staff membership to physicians with competing interests. Other hospitals prohibit physicians with competing interests from serving in leadership capacities. This is generally addressed in an economic credentialing policy adopted by the board.
Managing conflict
The way an organization handles conflict is often determined by its culture. Some cultures view every conflict as an opportunity to crush the competition through belligerence and bullying. Others are characterized by thoughtful responsiveness, sensitive to the feelings and concerns of others. A good starting point is to know your organization's style and then objectively analyze whether the strategic results are what you wish them to be.
Many organizations have little self-knowledge or recognition of their style. If we accept that conflict is a huge growth line in contemporary healthcare, then best practice is to design and implement a conflict management system.
In their book Designing Conflict Management Systems, Cathy A. Costantino and Christina Sickles Merchant state that there is a spectrum of alternative dispute resolution options that range from least invasive (those that allow disputants the most control over the process and outcome, such as negotiation) to most invasive (those that allow disputants the least control over the process and outcome, such as binding arbitration). What might such a progressive system look like for a medical staff and hospital?
Elements to consider, in ascending order of invasiveness, are:
- Prevention, which includes partnering, joint venturing, consensus building, setting expectations and rules, and joint problem solving. The physician-hospital compact, defining the give-and-take between physicians and hospital, is an excellent practice in this space.
- Principled negotiation to seek collaboration by separating people from the problem, focusing on interests and not positions, inventing options for mutual gain, and insisting on using objective criteria.
- Facilitation by using mediation, principled negotiation, and conciliation.
- Fact-finding mediation using a neutral expert.
- Advisory ADR using results of early neutral evaluation and nonbinding arbitration.
- Imposed settlement, such as binding arbitration.
- Legal remedies (only if all else fails).
Influencing culture
Culture is extraordinarily powerful and has the potential to undermine any leadership efforts and improvement. Recent literature addressing organizational culture has recognized that truly effective cultures must simultaneously embrace and balance interdependent opposites, sometimes called polarities. Common polarities seen in contemporary medical staffs include:
- Collegiality and excellence
We all want to work in an environment that is high on collegiality. Physicians appreciate working within a medical staff in which their fellow physicians work and play well together. Collegiality helps increase the social capital of a group or organization. This social capital is critical for providing the grease that allows smooth relationships and interactions within the medical staffs. In short, people who play together have a more difficult time fighting.
- Freedom and commitment
Physicians need the freedom to make choices about how to spend their time-on their practice, with their families, and on personal pursuits. This creates a dynamic tension that applies to physician participation in the organized medical staff. In this context, freedom means each physician's right to make individual choices concerning how to balance their practice, home, leisure time, and medical staff responsibilities. Each physician is autonomous and free to make these choices as he or she sees fit. Increasingly, medical staff members are opting to spend less time involved in medical staff activities or carrying out the board-delegated responsibilities of contemporary medical staffs. In many organizations, this absence of commitment and leadership has led to a crisis situation.
- Appropriate independence and mutual accountability
Appropriate independence is critical for the practice of good medicine. All physicians value the right to provide care to their patients as they deem appropriate for each case. Appropriate physician independence in the practice of medicine is an absolute requirement for physicians to exercise their clinical judgment and skills in the best interests of patient care. By virtue of training, experience, board certification, and undergoing rigorous and ongoing determination of current competency, physicians exercise their privileges to ensure quality patient care. This is consistent with the fiduciary responsibility of the physician to his or her patient.
- Appreciation and continuous performance improvement
We often fail to appreciate the excellent care physicians are providing already and the sacrifices they are making-attending patients in the middle of the night, dealing with angry patients who threaten to sue, and then coming in the next morning and doing it again. Who is saying "thank you" in your hospital? If physicians only hear from their medical staff about how they can improve, without being appreciated for the hard work and excellent care they are already providing, you won't have a healthy balance between appreciation and continuous performance improvement.
Once physicians feel appreciated and honored for the excellent quality of care they already provide, they are far more likely to accept constructive feedback and improve their care over time. In this sense, a medical staff culture that embraces appreciation and continuous performance improvement is more likely to be an effective medical staff.
- Stability and change
Culture is not changed easily and requires strong leadership. Leaders must espouse new beliefs and values, often in mission, vision, and value statements. Leaders must walk the talk and lead by example. They must be great communicators and reach out to fellow physicians to communicate about the new culture and the reasons for change. Leaders must also build strong social capital and respect to facilitate the necessary culture changes.
Cultivating influence
A fundamental principle underlying cultivating influence is that we are often interested in far more than we actually control; however, if we do well with what we control, we are able to increase our influence on things in which we have an interest but no control. Medical staff leaders should understand this dual role and responsibility of the medical staff. This principle applies to all parties. What is the sphere of control of the organized medical staff? First and foremost, it is their board-designated responsibility to monitor and improve the quality of care that is primarily dependent on the performance of individuals' granted privileges.
Because of this, physicians on your medical staff are accountable to each other for the quality of care they provide. This is a given. This is the sphere of control of the medical staff, namely how credentialing, privileging, and peer review are conducted in the organization.
But the medical staff is interested in many other things, including hospital operations (e.g., staffing, cleanliness, timeliness, availability of services, and competency of staff members) and the board-directed strategic development and initiatives of the hospital. To expand our influence, we must begin by doing what is in our sphere of control. Do what is in your sphere of control well, and your influence will expand. Don't do what is in your sphere of control well, and your influence will shrink.
Will your organization be characterized by unmanaged competition and war or extortion and capitulation, or will it be an organization dedicated to collaboration and ensuring physician and hospital success? Sailing the seven Cs offers a step-by-step approach to realizing the latter.
William K. Cors, MD, MMM, CMSL, is the vice president of Medical Staff Services at The Greeley Company. He can be reached at: wcors@greeley.com.