Physician Leadership: Key to Sustainable Health Care

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Physician Leadership Key to Sustainable Health
Care

• Jack Kitts M.D., MBA, FRCPC
• President and CEO,
• The Ottawa Hospital
• Associate Professor
• Department of Anesthesiology
• University of Ottawa

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• Beliefs
• The future of health care isnt something you
  predict, it is something you create.
• Physician leaders will embrace the turbulent
  environment and help shape the future of health.

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Objectives

• To gain insight into various pressures on
  physicians practicing in todays environment
• To understand the role of hospital administrators
  in todays environment
• To gain an appreciation for the importance of
  building trust and collaboration between
  physicians and administrators
• To learn what skills physicians need to become
  effective leaders

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Physicians are unhappy

• Doctor Discontent NEJM, 1998.
• Unprecedented numbers of letters to editor filled
  with passion and anger
• Physicians and the Changing Medical Marketplace
  NEJM, 1999.
• 46 of physicians surveyed often think about
  leaving clinical practice.
• World Study of Physician Attitudes BMJ, 2001
• 16 Very Unhappy 40 Unhappy 22 Neutral 17
  Happy, 4 Very Happy

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• 1 in 6 Doctors I am seriously considering
  leaving the Province of Ontario
• Survey of 2000 doctors in Ontario in December
  2003
• Ontario Physicians rank long wait times,
  under-funding of the system, and access to
  hospital services as immediate priorities OMA
  Press Release January 27, 2004

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Physicians in the Current Environment

• Increasing Accountability
• To the patient
• To the system

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Accountability to the Patient

• Hippocratic Oath
• Professional ideals that bind physicians to
• privacy of their patients condition,
• advocate for their patients well-being,
• do no harm.
• This is the ultimate accountability.

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Understanding Accountability

• In todays health environment, maintenance of the
  ultimate accountability and professional ideals
  are severely challenged by limited resources in
  the public health care system
• Physicians must willingly participate fully in
  discussions about necessary and appropriate
  constraints on health care costs.
• The conflict between the potential of medical
  science and the reality of limited dollars is
  permanent.
• Bodenheimer, T. NEJM, 1999

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Accountability to the Patient

• Family Docs / Specialists
• Diagnostics
• Therapeutics (surgical wait lists)
• Home Care
• Clinical Information
• Well-informed / Empowered patients (Information
  vs Knowledge)
• Physicians are accountable for quality patient
  care - but they do not control the system.
• Accountability without authority leads to
  frustration

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Accountability to the System

• Quality of Care
• Patient satisfaction
• Clinical outcomes
• Resource Utilization
• Length of Stay
• Expected Date of Discharge (EDD)
• Necessity of Admission (NOA)
• Standardized routes of admission (SDU, SDA, etc)
• Evidence-based Practice Guidelines
• Clinical Pathways
• Case Costing
• Benchmarking vs. Best Practice?

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Accountability to the System

• Ontario Hospital Report Cards
• System Performance
• Regional Performance of Hospitals 1998
• Hospital Specific Performance (1999 present)
• Physician Report Cards?
• The low-scar surgery with a high risk.
• The Toronto Star, September 1997
• Economic Credentialing
• Clinical Resource Utilization Policies and
  standards
• Practice Guidelines / Clinical Pathways
• (Accurate and timely data is lacking)

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Lack of Alignment in the System

• Federal / Provincial blame game
• results of various committees / commissions
  (Claire, Mazankowski, Kirby, Romanow, etc.)
  disappointing in terms of both funding and reform
• Hospital Administration / Medical Leadership

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Dear CEO

• I understand that your budget increase from the
  MOHLTC was less than the increased costs of
  inflation and wage settlements with the various
  union groups. I also understand that the
  Minister of Health will not allow budget
  over-runs, and you have to find 20 million
  dollars in cost savings this year.
• However, as Surgeon-in-Chief for your hospital, I
  must inform you that I can no longer recruit
  young surgeons and we are continuing to lose our
  best surgeons at an astonishing pace. Without
  immediate action, we will lose our Surgical
  Program.

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To ensure that we are able to meet the surgical
needs of our community and educate future
surgeons, I recommend the following

• Invest more money into house-staff extenders
• Invest more money into a major recruitment
  campaign including re-location expenses, signing
  bonuses, guaranteed incomes
• Supplement clinical earnings to achieve
  competitive rates
• Invest more money into administrative and
  research activities including increased office
  space and secretarial support
• Increase the OR and Clinic time for Cancer and
  Orthopedic surgeons at the very least
• Invest in state of the art medical equipment and
  new surgical technologies
• I trust that you will discuss this at your next
  executive meeting and support these
  recommendations.
• Sincerely,
• Professor and Chair of Surgery

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Aligning Administrators and Medical Leaders

• Need to understand the reality of rationing
  medical care within constrained resources
• Need a clear understanding of hospital mission
• Need to agree upon a shared Vision for the
  hospital
• Need to understand Directions on how to achieve
  the Vision
• Need to live the hospitals core values daily
• Need to clearly understand each others roles in
  carrying out the mission and working toward
  achieving the Vision
• Need to understand that hospitals will only
  succeed if physician leaders work hand in hand
  with administration to help show the way

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Who should be in control?

• Physician Perspective
• Since administration seems to have little
  understanding and appreciation for our patients
  needs, we physicians must continue to resist all
  this change and protect what little resources we
  have left.
• Administrator Perspective
• Physicians dont understand the impact of their
  choices on costs. They also dont understand the
  need to accumulate capital in order to be a
  long-term financially viable community resource.
  We administrators must control the physicians to
  the best of our ability.

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Need for Collaboration and Trust

• Responsibility suggests that rather than simply
  blaming each other and hoping that someone will
  fix the problems, physician leaders and
  administrators must constructively participate in
  creating collaborative solutions to both current
  and future challenges.

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Physicians Lead the Way at Americas Top
Hospitals The Physician Executive, 2001

• Physicians are involved in every aspect of the
  business. Thats one of the keys. In everything
  we do, physicians are pivotal.
• Melinda Estes
• Executive Director for Business Development
• The Cleveland Clinic

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Physicians as Leaders

• Chief of Staff
• Vice-President, Medical Affairs
• President of Medical Staff
• Hospital Department Heads / University Chairs
• Division Heads / Chairs
• Deputy Heads
• Medical Directors
• Hospital and MAC committees (health records,
  patient safety, etc.)
• CEO and other non-traditional roles in
  administration

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Physicians as Leaders Challenges

• Medical school and clinical practice may not
  provide physicians with essential skill sets for
  successful careers in management
• team building, communication, negotiation,
  planning, consensus, dispute resolution
• Management Accountability - Two Hats
• conflict as department head / chair vs hospital
  manager
• independent practitioner (appointment with
  privileges) vs hospital manager (reporting to a
  boss and subject to dismissal for poor
  management performance)
• Credibility with Senior Executives

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THE NEW TRADITIONALISTSBusiness Week Jan 21, 2002

• Survey of 1300 professionals age 26-37, (70
  women)
• Generation Xers rated various values and goals
  as being extremely important to them

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THE NEW TRADITIONALISTSBusiness Week Jan 21, 2002

• To have a loving family 84
• To enjoy life 79
• To share companionship with
• family and friends 72
• To establish a relationship 72
• To have a variety of responsibilities 22
• To earn a great deal of money 21
• To become an influential leader 16
• To become well known 6

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Leadership

• Leadership is the art of accomplishing more
  than the science of management says is possible.
• Colin Powell
• Giving people clarity of direction and a sense
  of purpose are central to strong leadership.
• Jim Collins
• Good to Great

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Leaders Key competencies

• Honesty, Integrity and Credibility
• Passion and hard work
• Fanatically driven by the success of the company
  not yourself.
• A paradoxical mix of personal humility (modesty)
  and professional will or commitment (to both work
  and family!)
• Attribute success to others look in the mirror
  to attribute blame for things that dont go well
• Great leaders are great simplifiers
• Dont shoot the messenger
• the day your staff stop coming to you with
  problems because they have lost faith in you, or
  they feel you dont care either way, you are a
  lost leader

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Physicians as LeadersWhat does it take to
excel? Ken Tremblay, Hospital Quarterly 2001

• Start Early
• get involved identify a mentor
• Accumulate Credentials in both Management and
  Leadership
• seminars, conferences, courses (PMI), degrees,
  etc.
• Prioritize
• gain experience with committees and task forces
• Commitment
• Develop an overall plan for the future and make a
  commitment. Discuss plans with appropriate
  medical leaders / mentors.

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Physicians as Leaders What does it take to
excel? (contd)

• Feedback
• Ask for feedback on performance
• Promotion
• Gain exposure to diverse experiences
• Practice
• Apply new skills and learning to actual
  situations in the hospital
• Seek out both management and leadership
  opportunities

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Moving Forward

• The opportunities for physicians to lead change
  and define the future of health care have never
  been greater. As complex issues continue to
  shape our evolving health system, physicians will
  play a greater role in leading and managing the
  system. A sustainable health system committed to
  high standards will not be realized without
  strong physician leadership.