A Prescription for Healthcare Leadership
The most visible battlefield for health care reform has and will likely continue to take place in the legislative and executive branches of our government. Unfortunately, the highly visible policy process creates antagonistic stakeholders each fighting for solutions that maximize self-interest. Predictably the outcome creates winners and losers and unintended consequences that set the stage for further dissatisfaction. Clearly reform is required, but improvements in the health care system could also emanate through a less contentious process that requires no government intervention.
In great part the cost and quality of healthcare are determined at the point of service where the physician ministers to the patient and prescribes the appropriate medicinal intervention. It is logical to initiate cost and quality improvements at this level. For example, creating more cohesive department teams are helpful to achieve performance outcomes, facilitate the flow of the delivery of care, improve communication, implement and review best medical and administrative practices, and establish a more effective learning environment. It is the ability to monitor and improve service at this micro-level that has the most direct, lasting, and beneficial benefits for providers, patients, and insurers alike.
What happens at the point of service is in part determined by the quality of local leadership. The work of each medical department is monitored by department chairs. Each specialty is lead by a physician department chair who typically provides oversight of the coordination of services, ensures the practice meets its financial and quality goals, responds to disciplinary matters, and provides information to and from senior management. Department chairs are often called upon to navigate complex and time consuming issues.
Unfortunately, most administrators and physicians expect the department chairs to play limited roles—to solve problems and ensure operational efficiencies are realized. They expect them to address physician personality peccadilloes, enforce policies, and intercede when conflicts erupt. Perhaps because of these limited expectations, department chairs are expected to maintain almost a full patient workload and receive limited additional remuneration. They typically have little time to exercise those activities that most of us consider crucial to implement change. They are forced to react to problems rather than spending adequate time strategizing, developing commitment to a larger vision, building department competencies, and building higher levels of engagement.
Elevating the expectations and role of department chair to provide proactive leadership can easily and cost-effectively improve critical aspects of the health care system. To do so requires following a three-course prescription: improve the roles and expectations of the position, provide additional leadership education, and create the time and the subsequent remuneration to undertake this work.
Improve the roles and expectations of the position
Most physicians chose the medical profession to improve the quality of life. In the course of their practice however, they are confronted with rules and regulations and administrative responsibilities that detract from the realization of their original mission. In many healthcare systems physicians feel less like healers and more like replaceable commodities. Many physicians prefer a stronger connection both to their professional colleagues and to the organizations they serve. But with health care delivery systems themselves under financial siege and a reward structure that incents piece work, physicians naturally become inclined to focus on their own short term performance.
The role of the department chair could easily be elevated to a team leader who inspires the department members to create and execute a more highly valued vision. Research indicates that focusing on possibilities rather than reacting to problems improves morale and increases productivity and performance outcomes. Department chairs would be expected to ask their members such questions as, “What’s really important to us? How can we distinguish ourselves? If we were working to our best, what would that look like?” Then they would organize all the players to achieve those possibilities.
The quality of health care cannot be improved by each specialty working alone. It is the integration of skills across specialties that has particular power to improve patient outcomes. Department chairs can also provide the mechanism to break down the silos between departments that typically plague most health care systems. These additional nodes of the internal network facilitate planning, communication, and feedback between the specialties.
Many department chairs avoid the critical work because they have never been taught how to do it. Just because they are great clinicians and/or researchers does not mean they know how to create a vision, deal with interpersonal conflict, or have the knowledge to conduct a productive meeting. My experience has been that though they are eager to learn and practice these new behaviors, few have the opportunity to do so.
Department chairs need a defined curriculum; they need to have regular opportunities to learn new skills and to practice them on real situations. Coaching by the Chief Medical Officer, Human Resources department or an outside consultant on a regular basis is required. This can be accomplished efficiently in bi-weekly or monthly joint department chair sessions that create greater skills, improve relationships between department heads, and ultimately contribute to a healthier culture and climate.
Time and remuneration
Department chairs devote almost all their time to direct patient care. If their role is primarily administrative, then perhaps the arrangement is acceptable. But if they are to have a significant impact on the manner in which their departments practice medicine, then they must have the dedicated quality time to do the leadership work. Higher level department objectives can be established. In addition to receiving remuneration for patient care, department chairs should be financially rewarded for accomplishing higher-level department and organization-wide initiatives. Perhaps they should also receive coaching support to help them achieve those objectives. The return on investment in terms of physician satisfaction, production, and quality outcomes are significant.
Making improvements to the health care system do not necessarily require new Congressional mandates or legislation. They do require a decision by senior leadership.