Wednesday, February 20, 2008

Health plans and doctors - Closing Hospital-Physician Relationship Gaps

Two years ago, James Hawkins, a former hospital CEO, and I wrote Sailing the Seven “Cs” of Hospital Physician Relationships (PSR Publications, 2007). The idea was that hospital CEOs had best patch up physician relationships by acknowledging the importance of CEO competence, convenience for doctors, clarity of communication with doctors, continuity of hospital policies, fair competition between hospitals and doctors, resolution of control issues, and fair distribution of cash.

Hospitals and doctors are at odds on such issues as who controls specialty hospitals and surgical outpatient facilities, patient safety and quality issues, and competition between hospital-owned physicians and independent practices.

The AMA has recognized the need for better relations by saying the organized medical staff should abide by these principles.

• Work with hospital governing bodies to improve patient safety and health care quality.

• Be responsible for credentialing and overseeing clinical quality and patient safety.

• Be involved in hospital strategic planning.

• Communicate with hospital governing body in a timely and effective manner.

• Establish binding bylaws that hospital bylaws or policies don’t undermine.

• Have inherent self-governance rights.

• Create bylaws that are binding and mutually enforceable between the hospital and medical staff.

• Determine how much money it needs to carry out the duties of the hospital governing board and to develop a budget the hospital will fund.

• Elect member representation to attend, speak, and vote at board meetings.

• Have individual members be eligible to be full members of board.

• Develop disclosure and conflict of interest policies for physicians in leadership.

• Address disputes with the hospital board through a well-defined process.

These principles are all fine and good, but a few flies are stuck in the ointment.

• The term “organized medical staff “is an oxymoron. The physician culture treasures independence and often acts independently of hospitals. The medical staff is not basically a coherent entity, since most doctors practice separately from one another.

• The “organized medical staff” is ineffective in overseeing business functions of hospitals. Hospitals know certain specialties – cardiovascular, orthopedic, other surgical and procedure-based groups, and oncology – account for 80% to 90% of revenues. Hospitals therefore tend to do “business” with these specialties, and where possible hire other specialties as employees.

• As Jeff Goldsmith, PhD, president of Health Futures has often observed, the chasm between hospitals and doctors is growing not shrinking. Goldsmith has written,

"As health systems integrated structurally, they disintegrated culturally. The gap between professional and managerial cultures that existed during most of the 1980s and early 1990s widened into a chasm by the late 1990s. Professionals of all stripes – not merely physicians, but nurses, technicians, social workers and others – saw their practices increasingly commoditized and marginalized by the growing corporate ethos in their systems; professionals lost contact, physically and spiritually, with the 'adminisphere' – the tiny handful of people running their systems."

Or as a management hospital operating consultant wrote in an email to me,

Most physicians distrust hospital senior management. A war is going on out there. Physicians feel hospital executives have no experience with the 24/7 responsibility of someone's life and the deep accountability necessary with care. My husband, an internal med doc in a large hospital has said the executive team has consistently failed in just about every endeavor to help. The failure gap widens.

Hospital senior management opposes changing organizational structure and processes to benefit doctors. Operational and financial deficiencies are widespread, and senior teams are engrained in a culture that ignores it and hopes it will go away. None have been willing to build real accountability among them. They are insular, protected, and ineffective in leading operational change.

The culture gap between hospitals and physicians will not be easy to close.


Unknown said...

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Thank you,
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Arrowsight Medical Launches Patient Safety Blog to Increase Awareness, Conversation
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