How Will This Module Help Me?
Learning Objectives
Recognize the current drivers of physician–administrator distrust
Explore methods to strengthen trust and transparency between practicing physicians and administrators
Outline strategies to improve physician–administrator relationships in your practice
Practicing physicians and administrators both rightfully consider themselves to be highly trained, skilled, and knowledgeable team members. However, relationships between frontline physicians and administrators are severely strained in many health care organizations, and trust is at an all-time low.1- 4
Physicians may feel that administrators don't understand, or don't care, about the challenges they face taking care of patients. They may feel as though they are treated as line production workers with little control over their schedules, support team, and even clinical decision-making. At the same time, administrators may think physicians do not understand the challenges of running a complex organization such as a hospital or health system, including the financial and management challenges that ensure long term sustainability.
This disconnect exacerbates key drivers of physician burnout, including5:
Building trust and transparency between practicing physicians and administrators has the potential to mitigate these drivers of burnout. This bridge can result in improved working relationships, healthier workplaces, increased personal and organizational resilience, and improved patient–physician experiences.
Four STEPS to Aligning Practicing Physicians and Administrators
Assess the Status of the Relationship
Open Communication Channels
Educate Physicians and Administrators on Each Other's Roles
Build Trust
STEP 1 Assess the Status of the Relationship
Before getting started, it is helpful to assess the status of physician–administrator relationships to understand the urgency of the issue and to direct the work. There may be significant events that alert the organization that there may be a breakdown in the physician–administrator relationship, such as:
An increase in physician turnover
Increased burnout rates on surveys
Decreasing ratings on physician engagement surveys
An exodus (or threatened exodus) of specialty groups
Increasing challenges with physician support for new strategic initiatives
A no-confidence vote for an administrator by physicians
If the organization senses there is an issue, more specific assessments can be performed. A good starting point is to evaluate physicians and administrators in leadership roles.6 An example of an assessment that can be used to evaluate leaders is the Mayo Clinic Leadership Index, a 12-question staff-wide survey of 5 key leadership behaviors.7
STEP 2 Open Communication Channels
Communication between practicing physicians and administrators (especially C-suite executives) is often lacking, leading to rumors and distrust. As health care systems have grown, it is more difficult for leaders to be in touch with, and deeply understand, the challenges faced by frontline physicians.
Many decisions made by administrators and their direct reports have unintended impacts at the point of care. Decisions about finance, IT systems, HR policies, and quality initiatives all impact the support physicians rely on to care for their patients. Strategic decisions regarding service lines or mergers and acquisitions can impact not only clinical care, but also community relations, for example by disrupting previously established specialty referral relationships.
Therefore, opening and maintaining communication channels is imperative. Ways to do this include8:
A CEO–practicing physician forum
Town halls
Online idea generators (see STEP 3 in the AMA STEPS Forward™ toolkit, Getting Rid of Stupid Stuff)
Social events without an agenda
If organizing a CEO–practicing physician forum, there are 2 approaches for deciding whom to invite:
Practicing physicians vote: Practicing physicians in defined departments or divisions select the representative of their choice who is not in a current leadership role. These representatives would attend regularly for a year or two, with subsets of attendees rotating off every 6 months to provide overlap and some continuity.
CEO selects: The CEO can invite a different group to every event, focusing on a specific division or groups with common issues.
The agenda of each forum should include:
Introductions
An update from the CEO
A roundtable discussion where every attendee has a chance to speak before general discussion begins
Wrap up with commitment to any specific follow-up items
Sample Email Invitation for CEO–Physician Forum (35 KB)Use this to invite practicing physicians to participate in the forum.
STEP 3 Educate Administrators and Physicians on Each Other's Roles
Educating Administrators: Shadowing Clinicians
Quiz Ref IDHealth care leaders, both C-level executives and members of boards of directors, are far removed from the realities of direct patient care. Building in time for administrators to learn about the daily experiences of frontline physicians through an immersion program can help bridge this gap and align the policies and strategies of the organization. Therefore, the goals of a shadowing/immersion program should be to8:
Provide non-clinician leaders with a deeper understanding of how their decisions impact patients, clinicians, and the clinical workplace
Build collaboration and trusting relationships between administrators and clinicians
Enhance administrators' commitment to fixing broken clinical workplaces
There are 2 ways that administrators can shadow practicing physicians:
Accompany individual clinicians while they are seeing patients
Attend team huddles on care units or in clinics
Regularly communicate your experience with either approach to the rest of your organization, ideally including positive comments from the clinicians and units you have shadowed.
Educating Physicians: Leadership Training
Quiz Ref IDPhysicians spend 7 to 10 years or more after college developing the knowledge and skills to become excellent clinicians. Despite the fact that during and after training they are viewed as leaders, they typically receive little training in leadership or management. While some physicians have natural leadership ability, all physician leaders can benefit from formal leadership development processes.
Physicians can gain leadership competencies in numerous ways. First and foremost is experience in a management role. Educational courses are important, but there is little value in gaining theoretical knowledge without personally experiencing the challenges of managing fellow physicians and other clinical and non-clinical team members.
Leadership and management courses are an invaluable adjunct to firsthand experience. They provide basic knowledge of the many areas of administrative responsibility that physician leaders are directly or indirectly responsible for: operations, quality, safety, population health, customer experience, human relations, health care finance, strategy, marketing, and informatics. Figure 1 describes some of the ways to pursue these educational opportunities.
In his landmark book, The Speed of Trust, Stephen M.R. Covey states that trust changes everything for the better by speeding up interactions and lowering costs.9 When physicians and administrators conduct themselves in ways that promote trust, it will flourish, and they will witness the difference in their organizations and their personal relationships.
Trust is key to ensuring effective and timely decision making in the high-stakes, complex, and changing world of health care. Here are 3 approaches to establish and nurture trust between administrators and practicing physicians:
Administrator–clinician dyads
Collaborative strategic planning
Organizational compacts
Administrator–Clinician Dyads
Many health care organizations pair their clinician leaders with administrative leaders in dyads (physician and non-clinician leader) or triads (physician, nurse, and non-clinician leader). Dyads are more common in medical groups and triads are more common in hospital settings. No matter the setting, these groupings can be successful and informative (Figure 2).
These groupings provide value in a number of ways:
For physician leaders, especially those early in their leadership journey, groupings support their ability to continue to practice medicine part-time without being overloaded with administrative detail. This enables them to maintain:
Credibility with the physicians they lead
Connection to and understanding of the challenges of clinical work
Clinical skills in which they are already invested
For administrative leaders, dyad or triad groupings provide the opportunity to better understand clinical care as well as to provide value by educating their dyad partner
For both the physician and administrator, dyad leadership:
Ensures consistent messaging to both physicians and their support teams
Models how physicians and non-physicians work together
Reduces gaps in leadership access when the dyad partners can cover for each other
Collaborative Strategic Planning
Strategic planning requires analysis of complex data, choosing among multiple options often without a clear best choice, working with others to gain support, and taking action to realize a better future. There are strong analogies to how patient care is approached, especially for patients with complex medical problems and high-stakes risks. Therefore, there is significant benefit to strategic planning when executive leaders and physicians work together in the process as trusted colleagues. Not only does this produce a higher likelihood of strategic success, but it also enhances the ability of the organization to adapt to a changing environment, which is key to survival in times of uncertainty.
Organizational Compacts
Most health care organizations have a stated set of values, which can include things such as quality, service, integrity, financial stewardship, etc. These values provide guidelines for how the organization will honor its vision and mission statements. It is important to state the values to help stakeholders know what is important in the organization. But if the values are vague and open to individual interpretation, they can add to the drivers of burnout.
An organizational compact is a document that codifies what are usually unwritten reciprocal agreements between 2 or more parties. Unlike formal contracts, compacts are based on organizational values. The benefit of a compact is that it adds clarity to each value. The compact states specific expectations for how each party will honor each value. These expectations are reciprocal. For each value there is a statement that says the organization can expect the physician to do “X”, and, in return, the physician can expect the organization to do “Y”.
For example, the compact can detail specific actions/behaviors for the vaguely stated value of “quality”:
Physicians will maintain current clinical competence and collaborate with other members of the patient care team to follow accepted quality guidelines.
The organization will provide a clinical environment (eg, staffing, equipment, supplies, and physical plant) that supports quality care.
Example Organizational Compact (31 KB)See a real group compact from Sutter Gould Medical Foundation before drafting your own.
These 4 STEPS aim to bring practicing physicians and administrators together to build connections, trust, transparency, and mutual respect. These factors are all vital to both personal and organizational well-being. It is important to remember that accountability is key—the activities recommended here will build trust only if they are done consistently, with appropriate documentation and tracking of progress. This consistency will help to maintain strong and successful bridges between administrators and practicing physicians in the rapidly changing health care environment.
Journal Articles and Other Publications
* Kornacki MJ, Silversin JB. A New Compact: Aligning Physician-Organization Expectations to Transform Patient Care. Health Administration Press; 2015.