Healthcare Leadership | Physician Integration - Hospitals & Health ...

By Nathan Kaufman	October 24, 2012
Embracing conflict, soliciting opposing views, being willing to change your mind and your behaviors ? these tactics are all critical to the success of your organization.

Editor?s note: This is the final installment in ?From the Trenches,? a monthly series we have published between May and October.

Retreat season is in full swing. Health systems and medical groups are dedicating their weekends to learning about the future of health care, analyzing the implications of trends in their markets, and formulating a path for the next several years. In addition to the formal retreat programs, time is allocated for socializing, usually involving adult beverages.

As a participant in many of these retreats and their associated after-hours activities, I have identified one characteristic common in virtually all health care provider systems and groups ? conflict.

Conflict takes many forms, including:

• boards versus managers over roles and responsibilities
• medical staff members versus administrators over autonomy versus standardization
• those with a vision of a sea change in health care versus those who believe that the status quo eventually will be preserved
• those aggressively pursuing Medicare accountable care organizations, medical homes and bundling versus those taking a wait-and-see approach
• physicians who think that they are not paid enough, versus administrators who think these physicians are paid fairly
• internists versus critical care specialists regarding privileges in the intensive care unit

While some view this conflict as a sign of failure, the literature is clear: Constructive conflict should be expected, and organizations that embrace conflict, rather than avoid it, usually make better decisions.

Most health care systems comprise a series of alliances of independent providers. As noted in their article ?Simple Rules for Making Alliances Work,? Jonathan Hughes and Jeff Weiss found that the failure rate for alliances [for all businesses] is 60 to 70 percent. The authors note that ?[a]lliances pose special challenges that make traditional management practices irrelevant ? . [P]articipants must navigate often-maddening differences in operating styles, focusing less on the business plan and more on the partnership?s working relationship and, rather than suppressing disagreements, conflicts should be analyzed to find sources of value in partners? differences.?

Conflict in Reorganization

Health care organizations that have successfully transformed from the traditional delivery model to a ?second-curve,? value-focused, patient-centered delivery system, such as Virginia Mason Health System, experienced a cornucopia of conflicts during their journey. In the Harvard Business School case study for Virginia Mason, published in 2006, chairman and CEO Gary Kaplan, M.D., explains that ?[t]he implicit compact between the hospital and its physicians was about entitlement, protection and autonomy. By virtue of joining the medical group, each physician felt, ?I?m entitled to patients, I?m protected from the environment by administration and I can do whatever I want, whenever I want to.??

Recognizing that the organization needed to become more efficient and accountable, the leaders of Virginia Mason adopted the Toyota Production System to improve the quality and efficiency of care. But this was not without conflict:

?We don?t make cars, we treat patients!? explained disinclined Virginia Mason providers, according to the case study. They opined that Toyota Camrys cannot be compared to patients with unique diseases and complex emotions. Many doctors and nurses contested that they did not work on a production line, so it was impossible to transfer Toyota principles to the medical center. How can providers standardize care, they argued, when each patient is different?

In the early days of the Virginia Mason Production System (VMPS), there was some staff and physician attrition: 10 physicians left the medical center. ?People left because they knew they wouldn?t fit into the new culture,? Kaplan noted, ?or they weren?t comfortable with VMPS, or they just didn?t like the change ? . One of the hardest things for me to realize was that not everyone wanted or was able to come with us on this journey. I recognized that you have to say goodbye, and this is a good thing. You can?t keep everyone happy.?

Conflict in Improving Care

The Affordable Care Act is perfectly designed to create constructive conflict, especially as it relates to forcing the true integration of physicians and hospitals. The intent of value-based purchasing, withholds for high readmission rates, and Recovery Audit Contractor audits are to penalize hospitals for the poor collective performance of the hospital and its ?independent medical staff.? A medical staff composed of physicians who do not document accurately, who hand off discharged patients poorly, who fail to adhere to government-issued processes and who communicate badly with their patients, eventually can cost a hospital 6 to 8 percent of its annual Medicare payment.

In the case of documenting medical necessity, the penalties can even be more severe ? it can lead to fines. While hospitals have been employing and co-managing with their physicians, few have challenged their physicians? individual clinical autonomy.

Also, many innovative hospitals now recognize that their management structure must change; they are yielding traditional administrative authority to physicians who understand the new model for clinical care, who overcome resistance from their colleagues, and who drive necessary change. At Memorial Hermann in Houston, for example, standardization and clinical transformation has been delegated to the physician leaders.

It is essential that we ?suits? recognize that physician leadership is critical to transforming the health care system, and that this transformation breeds conflict. At the national level, Atul Gawande, M.D., espoused the notion of using checklists before surgery. And in his book Unaccountable, Marty Makary, M.D., calls out the tradition of physicians who overlook the mistakes of their colleagues, thereby breaking a code of silence in the physician culture and stirring a national debate (and conflict) about transparency.

At the health system level, Brent James, M.D., of Intermountain Healthcare has introduced standard protocols that measurably improved the quality of patient outcomes; and Keith Fernandez, M.D., and his colleagues at Memorial Hermann are building a high-functioning, clinically integrated network of physicians in Houston.

Conflict in Creating Change

Why does it take an average of 17 years for the established medical community to embrace an evidence-based protocol, and why does improving patient care based on the best science in medicine result in so much conflict? In her TED speech Margaret Heffernan explains: ?The data [about the harmful effects of X-raying pregnant women in the 1950s] was out there, it was open, it was freely available, but nobody wanted to know ? . Openness alone does not drive change.?

Constructive conflict is not about acting out, or who can be the most stubborn or shout the loudest. Constructive conflict requires:

• viewing conflict as a natural phenomenon and not a failure;
• creating a culture that views conflict as healthy and not personal;
• embedding a process for efficiently resolving conflict within the organization by using data, and within which all parties practice radical transparency;
• soliciting the help of a mediator when necessary;
• showing no tolerance for those who act inappropriately (one hospital and its physicians have adopted a ?no jerks policy?); and finally,
• agreeing that the decision at which the group arrives will become the standard of practice for all, even if an individual disagrees.

As Heffernan says in her closing comments: ?The fact is that most of the biggest catastrophes that we?ve witnessed rarely come from information that is secret or hidden. It comes from information that is freely available and out there, but that we are willfully blind to, because we can?t handle, don?t want to handle, the conflict that it provokes. But when we dare to break that silence, or when we dare to see, and we create conflict, we enable ourselves and the people around us to do our very best thinking.?

Nathan Kaufman is the managing director of Kaufman Strategic Advisors LLC in San Diego. He is also a member of Speakers Express.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

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