17 July 2015
Dear Interested Readers,
Inside this Week's Letter
There is only one subject in this week’s letter. It is one of the most discussed strategic issues in healthcare, the engagement of physicians in the process of transformation of their practices and our system of care. It is a complex subject and I try to use the work of others to suggest that success will require some new approaches. I try to lead you to the conclusion that traditional attitudes and management approaches are not going to work well. Success may be a function of leadership’s skill deploying knowledge, attitudes, tools and skills that some managers might consider “soft”.
I conclude with some philosophical observations about fishing, the second half of the baseball season and the growing apprehension and concerns about Tom Brady post deflategate.
As always let me remind you that your friends can sign up for this letter on the strategyhealthcare.com website where you can find shorter versions of some of these same ideas.
Physician Engagement, Not a Simple Issue
Everywhere I go there are the same recurrent questions and concerns. The list usually includes issues like:
- How do we manage the shift of our business systems to be successful in a future with value based reimbursement and more performance risk while we are dependent on FFS income?
- How do we do population medicine?
- How should we compensate physicians?
- How do we clinically transition from how we work now to the way will need to work in the future?
- How do we engage physicians?
All of these issues came up simultaneously in a letter that I received this week from an Interested Reader. The letter was a succinct statement of most of the core challenges that face physician leaders and their business counterparts all across the country.
Gene,
It’s been awhile so I thought I’d check in with you. Things are going well here... The challenges here are enormous. We are trying to move a huge system to value-based care in a state that has known only FFS and where for profit payers dominate the market. Our network is about 2/3 private practices and 1/3 employed physicians. We are trying to put systems in place to do population management and at the same time convince physicians this is where they need to go. Just as you mentioned in one of your recent musings, specialists are the most skeptical. They don’t see the value of the changes. In many of our speciality practices they are fairly blatant about their focus on maintaining and even increasing their incomes. A number of groups are jockeying about, moving from network to network as they try to find a deal that will pay more and ask them to do a little. I suspect they will at some point soon have an unpleasant surprise. I am trying hard to help the folks here focus on where they need to go, think strategically, and use LEAN methodology in a disciplined way. It will be a tough pull. I don’t think they are totally ready for what I am selling….
At every conference that I have attended over the last five years the questions vary a little but are a pretty good match to this Interested Reader’s list of current concerns. The questions discussed at the conferences always include some iteration of the physician engagement question. Long discussions follow and the the answers must be inadequate or difficult to implement because at the next conference the “How do you engage physicians?” question is back on the list of “hot topics”. [Hot topics is the multi-voted list for open-mike discussion at GPIN.]
Some consultants and some organizations do believe they have the answer. Quint Studer has written many books about change management in healthcare and the necessity of leadership engaging all employees, but specifically physicians. Studer has a following and apparently many have been successful adopting and implementing his ideas and methodology. Several successful organizations have augmented their transformation by going through extensive “Compact” processes advocated by Jack Silversin and Mary Jane Kornacki through Amicus, their consultancy. The Amicus methodology is meant to positively engage physicians through discussions about the interdependent roles and responsibilities of the practice and management and has been successful at ThedaCare, Virginia Mason and Harvard Vanguard Medical Associates as well as other organizations.
As a physician who was once very focused on my own clinical autonomy and very suspect of the motives of the administration of my practice, I realize that there is no one physician mindset. The variation in the mindset of physicians surely contributes to the complexity of engaging the profession. I recently found on the Internet an excellent 2013 article from McKinsey, the consulting firm, that underlines the variation in physician attitudes. The analysis in the paper is based on an extensive 2011 survey of over 1400 physicians from every type of practice, most specialties, and every region of the country. I also know from my own experience that the ability of management to engage me as a physician changed substantially as my experience and insights evolved as I continued in practice. All physicians are not of the same mind and most physicians change their view of the world and their relationship to practice as time goes forward.
The inherent differences between physicians as individuals and the evolution of the attitudes of professionals as they continue in practice insures that all physicians will not respond to the same mechanisms for engagement. There are also unique circumstances with each practice environment. There is no single answer to how to engage physicians, which is probably why the issue persists and the question is asked and again as if it has never been answered. The variation in the attitudes and mindset of physicians arises also from generational differences as well as experiential and personal variation. The old analogy that leading physicians is like “herding cats” has validity.
Leading and engaging physicians over the last twenty years in the era of change has required leaders to have new competencies. As we moved from the heightened awareness that followed To Err Is Human and Crossing the Quality Chasm into an attempt to transform practice in response to the issues of quality, safety, access and cost, successful leadership has required that leaders become better communicators and much more familiar with the issues and skills of managing change. Successful leaders have tried to augment traditional leadership skills with new knowledge of behavioral economics, change management, effective negotiation, and communication theory. Their success has required the development of new “soft” leadership skills as well as the concurrent mastery or understanding of a very complex social and business environment as they face the challenge of engaging physicians in the process of clinical transformation.
Shortly after becoming a CEO I had a personal experience that informed me of the difficulty of the road ahead. My predecessor had involved Atrius Health in a very exciting opportunity that had been offered by Blue Cross. Five organizations, Atrius Health, Mount Auburn Hospital, New England Baptist Hospital, Beth Israel Deaconess Medical Center and Cooley Dickinson Hospital in Northampton had each been given 1.5 million dollars to “do something remarkable” to improve care. That was good, but the best part for me was that once a month the CEOs of the five organizations were required to meet for an all day seminar. The whole process was called "Lead". On the meeting days we would hear the reports of the ongoing work and we would also be treated to a visit with a CEO from a remarkable organization from another part of the country. I loved the forum and the CEOs learned much from the outside speakers and from each other as we developed effective relationships from which future collaborations would develop.
The outside speakers came from organizations like Cincinnati Children’s, Allina in Minneapolis, McLeod Health in South Carolina,and Jönköping one of the progressive counties in Sweden where population health was in an advanced state of development. One of our experiences was a trip to Dartmouth to spend the day with several of the investigators at the Dartmouth Institute. I had great expectations for that session because it was my first meeting and I was excited about the opportunity it offered me to meet the great Paul Batalden, developer of the “microsystems” concepts and author of the startling statement,
"Every system is perfectly designed to get the results it gets”.
If you visit the offices of IHI you with find Batalden’s quote painted on the wall. Batalden was the Founding Chair of the IHI Board.
As luck would have it I found myself sitting next to this man for whom I had such admiration. It was a long day and as the hours progressed I became increasingly aware of Dr. Batalden’s affect. He was not saying much and when he did speak there was an undertone that felt as if he was drawing his words from a reservoir of concern and worry. The sense became so strong toward the end of the day that I became concerned that he might not be feeling well, so I asked him if there was any problem. He quickly reassured me that he was well but then confessed that he was worried.
He was worried that the work on systems improvement as a mechanism of improving the quality, safety, access and cost of care was vulnerable. He said that he was concerned that he and his colleagues may not have done enough to establish the importance of these issues to the practicing community. It was certain that they had been heard, but was action being taken in an effective way? Did younger physicians understand the work that had been done, and were there sufficient numbers of them to carry on the work to further success?
At the time he was already past his sixty fifth birthday and I sensed that he realized that he had done most of what he would be able to do, and it was as if he was holding himself accountable to the unanswerable question of whether he had done enough and had he done his best. The answers to his two questions in my mind were, “Without a doubt” and “Definitely yes”. He went on a little longer to talk about the lack of engagement that concerned him and pointed out that the work could be completely lost and all accomplishments essentially voided in less than twenty years unless the majority of young physicians could be recruited to the philosophy of quality improvement.
You can imagine my surprise when recently I found a three and a half minute YouTube clip of Dr. Batalden talking about issues including the engagement of generations of clinicians. What is amazing is that his words to the camera were exactly the same conversation with almost the same affect that he displayed in the response to my question to him in 2008.
I include a lot of links in these notes and I realize that you have much better things to do than follow a lot of links. That is why I always try to tell you what you will find if you use the link. I am respectful of the investment of your time. I am grateful for the time that you invest in reading these letters. The links are there in the letters just in case you have a deeper curiosity, but I hope that all of you will watch this video. In it Paul Batalden describes succinctly why we must be engaging more “smart people” now and just how vulnerable what has been accomplished really is. Unfortunately, he does not tell us how to engage more “smart people”.
Here is a rough transcript of what he said:
Perhaps the overarching question has to do with a challenge and what it will take to build a shared sense of the requirements for linking better outcomes for patients and populations, better system performance for quality, safety and value and better professional development for the competence, and joy and pride in professional work. But there are a few subsidiary questions related to that and the first of those subsidiary questions is what can be done to facilitate the meaningful transformation and the application of that information to practice. Practice by smart, capable people. The closely related question for me about all of this, is learning to hold our beliefs or how can we hold our beliefs properly so that we are able to accept both confirming and disconfirming information. Fourth, what is the knowledge and encouragement that we need to attract the creativity and the resourcefulness and the will of the people that we need, to lead the improvement of quality, safety, and value in healthcare at a time like this. And lastly, what’s the best way to achieve the proper blend of cooperative and competitive behaviour.
Well, most importantly it’s been recognizing and encouraging good work but it’s also happened by linking people and opportunity and it has also happened when I’ve stopped trying to help everyone and everything. And that’s related to me and others like me, recognizing that each of us only gets a turn at all of this. I think it’s important to know the importance of stopping, stopping and then helping people who pick up what you have stopped. And lastly by always trying to work one or two generations ahead.
I fear that the Greek God of Time, Chronos, has a deep and pervasive hold on us, on our calendars and our diaries and our schedules and I think the only powerful enough force to confront Chronos are deep, authentic, personal interactions. We can’t just be a click away, we have to really confront Chronos with the force of the whole person.
As I said above, I was moved by Dr. Batalden’s conversation and agreed with his concern that we need to have a dialog that attracts smart people. We need to be honest enough to be uncertain and invite their ideas, realizing that no one has a lock on all the answers. In a Lean process when our experiments reveal that our hypothesis has not been confirmed, we can accept the outcome as new data and use the new information to continue the exploration for a better system of care together. I think that is what he meant when he said:
“...what can be done to facilitate the meaningful transfer of information and the application of that information to practice, practice by smart, capable people. The closely related question for me about all of this, is learning to hold our beliefs, or how can we hold our beliefs properly so that we are able to accept both confirming and disconfirming information.”
Below you will find three other presentations that confirm his core ideas about the importance of dialog in the engagement of physicians. The first is a slide deck that was a presentation given by Jack Silversin at the IHI in 2012. The second article is a “free” download of an article in the Harvard Business Review by Toby Cosgrove, the CEO of the Cleveland Clinic, and Tom Lee, the former CEO of the Partners ambulatory practice and now the CMO of Press Ganey. The final article is the McKinsey discussion of physician engagement that I mentioned earlier. Below I will try to weave for you what I learned by comparing their recommended approaches to physician engagement.
My first exposure to Jack Silversin and his ideas about physician engagement was 20 years ago when he was invited by Glenn Hackbarth to speak to our practice. I was taken by his ideas, but our management did not engage him at that time. Later, more than fifteen years later, when I was CEO, we asked him and his partner at Amicus, Mary Jane Kornacki to come back and help us with our efforts to engage physicians.
A core idea of Amicus is that the anger of many physicians stems from their sense that the work they are being asked to do is not consistent with their “implicit contract”. Their idea was that they treat patients and provide “personally defined” quality care in exchange for autonomy, protection and entitlement. That is a contract that can no longer work and must be replaced by a contract where physicians are actively engaged in quality improvement. Physicians must share a vision with leadership, treat everyone with respect, engage in collaborative practice and support innovation. In exchange for their engagement physicians can expect inclusion in significant decisions. They can trust management to be transparent about issues of finance and how decisions are made. They can also expect appreciation of their efforts, a responsible management that effectively runs the practice or hospital, and improved access to clinical data and physician performance relative to benchmarks.
Silversin and Kornacki believe that this new environment can only be achieved if it is always safe to be honest. It must be safe to ask questions. Management must not be judgemental. Trust must be built and engagement must be an organizational expectation. There must be shared assumptions and beliefs. Quick fixes should be avoided. Change is managed as an “adaptive” process, realizing that there will be moments of disequilibrium, distress, and work avoidance as hearts and minds slowly change through experiments to find a better way together. Silversin and Kornacki envision engagement as an outcome of a process. They do not expect engagement to be a sudden occurrence of the acceptance of a forcefully presented idea or demand.
Cosgrove and Lee are leaders who can say with authority, “Been there, done that.”. Their ideas must command attention based on what they have accomplished. I love the way they begin their piece:
Despite wondrous advances in medicine and technology, health care regularly fails at the fundamental job of any business: to reliably deliver what its customers need. In the face of ever-increasing complexity, the hard work and best intentions of individual physicians can no longer guarantee efficient, high-quality care. Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.
And yet, many physicians are deeply anxious about the changes under way and are mourning real or anticipated losses of autonomy, respect, and income. They are being told that they must accept new organizational structures, ways of working, payment models, and performance goals. They struggle to care for the endless stream of patients who want to be seen, but they constantly hear that much of what they do is waste. They’re moving at various rates through the stages of grief: A few are still in denial, but many are in the second stage—anger. Bursts of rage over relatively small issues are common.
Given doctors’ angst, how can leaders best engage them in redesigning care? In our roles in senior management of two large U.S. health care systems, and as observers and partners of many others, we have seen firsthand that winning physicians’ support takes more than simple incentives. Leaders at all levels must draw on reserves of optimism, courage, and resilience. They must develop an understanding of behavioral economics and social capital and be ready to part company with clinicians who refuse to work with their colleagues to improve outcomes and efficiency.
Their presentation fits the concept of a reason for action and a description of current state and then gives us a preview of the solution. Their hypothesis is that the engagement of doctors is necessary because anything that doctors do not embrace is doomed.
Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.
Cosgrove and Lee have a methodology.
- Get started by clarifying goals and gain agreement from physicians not to “sabotage” the process but become fully collaborative in “relentless improvement”.
- Engage in “shared purpose”, something positive, noble, and important for patients. Leaders must frankly acknowledge the need for sacrifice and articulate a vision of what lies on “the other side of turmoil”. The conversation is not about compensation.
- Appeal to self-interest. Channel some compensation through performance goals that produce value for patients.
- Use nonfinancial rewards (recognition) and penalties (group opinion, peer pressure) based on transparency to drive behavior. “...doctors, knowing that their performance is on public display, are strongly motivated to improve.”
- Embrace tradition. Use the desire to be affiliated with a great organization to align performance.
- Focus on operational objectives. Operational achievements confirm the benefits of engagement.
Although the authors begin by talking about engagement the paper reads like the title should have been “performance management”. I have no objection to combining the two concepts but the transformation of practices and hospitals that will add up to an improved system of care will require more creative engagement than performance management.
The introduction to the McKinsey paper is also a well written reason for action with a focus on finance. The bolded portion is my addition. A confluence of events is advancing a “total cost of care” savings agenda in the US healthcare industry. Although the rate of growth in our healthcare spending has slowed in recent years, expenditures continue to rise. The United States now devotes almost 18 percent of its GDP—more than one in every six dollars earned—to healthcare.
A step change in operational and clinical performance across the healthcare value chain is needed. This transformation requires robust leadership, and much of that leadership must come from clinicians, especially physicians. Not only do physicians make many of the frontline decisions that determine the quality and efficiency of care, but they also have the technical knowledge to help make sound strategic choices about longer-term patterns of service delivery. Without physician engagement, even near-perfect execution on operational efficiency and utilization management will be insufficient to drive the necessary level of change and will never truly be sustainable. Thus, the active participation of physicians throughout the healthcare value chain, from individual practices to the national level, is mandatory for any provider or payor that wants to eliminate unnecessary costs or capture value from innovative partnerships (e.g., by reducing clinical variability and strengthening care coordination across settings).
For those who want to learn how to more effectively engage physicians, the contribution of the paper is the insight that the survey of attitudes of 1400 physicians offers. This is valuable information for the leader who is trying to effectively engage physicians. The data offers many insights but the chief lesson is the necessity of leaders to communicate specific details about finance and risk. They make many of their points with quotes from physicians.
Of course I care about costs. And I know I need to be careful about where I send my patients. I don’t know a single doctor who isn’t trying to figure out how to be more efficient, or how to be better coordinated for our patients. I guess I’m just not sure exactly what it is that I would change about my day-to-day work to do that. —Primary care physician
No one teaches you about cost containment; you have to figure that out for yourself when they start complaining that you are ordering too many tests or admitting too many patients. I actually think a lot of doctors would be shocked at how much it costs for them to treat a patient. We don’t even look at the numbers— we’re not responsible for them. It’s very easy for me to order a bunch of tests if I have no idea what they cost. —Orthopedic surgeon
Risk sharing is the way to change the way we practice. We need to be compensated for doing the right thing, not just for seeing more patients. You have to link who is making the decisions with who has to pay. Right now, the insurance companies and hospitals are paying, but the doctors are making the decisions. —Cardiologist
The McKinsey interviews revealed that more than 70% of physicians know that they will eventually need to embrace change but less than 20% of them have begun the process or have been offered the opportunity to be engaged.
The themes that come through to me from all three discussions are:- The necessity of a new skill set for leadership that includes the ability to lead the building of a shared vision.
- An environment of trust that fosters an open and honest dialog. Management must believe that the ideas of physicians are important in the search for solutions.
- The importance and difficulty of respectful, effective dialog is core to engaging physicians.
- There is benefit to a negotiated patient centered vision or shared purpose.
- Physicians have a steep learning curve before they will be able to be comfortable with or trust new finance mechanisms.
- The effective and respectful use of transparency can go a long way in the struggle to build trust and engage physicians.
- There are possible benefits in the attempt to use rewards during the alignment of transformation with a physician’s self interest.
- Engaging physicians in meaningful change will be a long process that will require a consistent approach through several generations. We will always be at risk for the loss of hard won gains as batons are passed. (derived from Dr. Batalden)
My observation is that almost all of the wisdom and the objectives that are described as important through this examination of recommendations is achievable with a successful Lean transformation. The outcome of the Atrius participation in the “Lead” program and the use of that 1.5 million dollar grant was to jump start our Lean journey. Participation in Lean is a very effective way for a physician to become engaged in clinical transformation. I Think That I am Better Off Fishing Most evenings in the spring, summer and fall you can find me pedaling my kayak around the lake with a flyrod in my hand. Most of the time I just let my fly trail along thirty or forty yards behind me in the wake of my kayak. I admit that it is a lazy man’s approach to fishing. I am always surprised when the rod suddenly jerks in my hand and the reel begins to whir as the fish fights against the drag that I have applied. I am fortunate that my lake has an abundance of beautiful rainbow trout like the one pictured in the header. Rainbows are a pretty genetically engineered species and the State's Fish and Game Commission puts about 1500 new ones into the lake each year to live with the good old largemouth and smallmouth bass that have always called the lake home. I enjoy landing any fish. After I catch a fish I always give my visitor a few words about the downside of impulsive behavior. I take their picture as proof of my catch and then let them go with the hope than in the future I might see them again.
On most evenings I am visited by loons and on special evenings a gorgeous eagle or a majestic heron comes into my view. The scenery is always spectacular and even though it is the same lake every night there is almost always something new to see and appreciate that I have never seen before. Being a multitasker, I often listen to “tunes” or baseball while I fish.
This has been a great season for fishing, but not such a good year for Red Sox baseball. I am very apprehensive about the remainder of this season. It seems a little early to begin to think about the 2016 season and another journey toward disappointment. Organized sports, or rather professional sports, are not working so well for me. I am not sure whether we have heard more coverage of “deflategate” on the radio each day or more coverage of the Greek financial crisis. I hear as much discussion of Tom Brady’s threatened legacy on radio and TV as I hear discussion of the President’s legacy. I wish there was a better and more direct way to justify improving the infrastructure of Boston than to attract the 2024 Olympics. Thoughts like these underline for me why I fish. When fishing the expectations are that if anything happens it will be good, and when on those rare occasions that nothing happens, everything still seems just fine!
I hope that your summer is going well and that whatever you enjoy doing you are doing a lot of it and that you are also taking the time to do the things that improve and preserve your health.
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