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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:
Lack of control
Breakdown of community
Perceived absence of fairness
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.
Assess the Status of the Relationship
Open Communication Channels
Educate Physicians and Administrators on Each Other's Roles
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
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
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:
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
Use this to invite practicing physicians to participate in the forum.
What is the value of a CEO–physician forum?
CEOs benefit from direct feedback about the impact of leadership decisions on patient care. Even physicians in C-suite positions who practice part-time have limited exposure to the realities of full-time practice in their own field, let alone in other specialties. This forum's goal is to help the CEO understand the realities faced by practicing physicians.
The key is to schedule meetings between the CEO and 6 to 8 practicing physicians every 2 to 3 months. These regular meetings are best held over a meal away from the office to create a more open, relaxed atmosphere.
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
Shadowing Individual Clinicians
The following key factors can ensure a positive shadowing experience:
Ask permission to shadow clinicians.
Prepare your people. Educate all stakeholders (clinician, local staff, leaders) about what you are doing and why.
Prepare yourself. Your goal is to understand and empower the local team. You will be observing to learn about the challenges, not to fix issues for them.
Schedule time to shadow and to debrief ASAP afterwards. Do not cancel these appointments.
Schedule regular shadowing (every 1 to 2 weeks) with different clinicians to learn about your organization as broadly as possible.
The same approach can be taken by holding an “immersion day” in which board members and senior leaders spend a day in scrubs shadowing a variety of clinicians throughout the day.
Attending Huddles in Care Units or Clinics
The second way for administrators to learn more about the perspectives of practicing physicians is to sit in on their regular meetings or huddles throughout the workday. Effective huddles include 5 components:
Sharing appreciation for 1 of the team members
Preparing for the day ahead (eg, assessing supply and demand issues)
Identifying a process to solve the problems
Tracking performance metrics at the unit level
By observing the huddle, the administrator can assess how well the team is able to perform the huddle and understand their challenges, but not solve their problems for them. This reserved approach helps administrators assess the effectiveness of their management processes and leadership development programs for the management team.
The administrator can take 2 actions during the huddle:
Ask clarifying questions to better understand
Provide positive feedback to encourage the team
Any negative comments or suggestions for solutions to problems they heard about during the huddle should be reserved for when the administrator debriefs with the local leader.
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:
Collaborative strategic planning
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.
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.
See a real group compact from Sutter Gould Medical Foundation before drafting your own.
Do all members of a dyad or triad have equal authority within the unit? How is disagreement resolved?
Dyads should be carefully developed, with members chosen for compatibility, trained together, and coached to find agreed-upon answers. If there is an unresolvable dispute, then the issue should be escalated to the dyad they report up to.
What are some pitfalls with dyad and triad relationships that we should anticipate and how should we mitigate them?
Dyad and triad teams need to be chosen carefully, with joint approval from the leaders the team will report up to. Over time, as they work together on projects and solve problems, dyads and triads develop a level of trust and collaboration so they can each represent the other in meetings with their direct reports.
Why are physicians invaluable in strategic planning?
Physicians play a vital role in strategic planning because they:
Are highly trained, skilled, and knowledgeable team members who have spent the majority of their time at the forefront of patient care
Have training and work experience delivering patient care that often requires collaboration, a valuable component of effective strategic planning
Practically and conceptually have their “finger on the pulse” of care delivery, living the challenges of the current models of care and readily identifying opportunities at the micro and macro levels for improvement and innovation
Regularly learn about the latest innovations in workflows and treatment protocols by reading literature reviews and connecting with colleagues online and at conferences
Will be the ones implementing the new strategic initiatives, thereby ensuring the clinical, operational, and financial success of new initiatives
What challenges do physicians face in strategic planning?
Many physicians are not trained to analyze market data or review financial projections. They may favor an initiative that benefits their own specialty over others, potentially supporting efforts that provide less benefit to the community. However, most are deeply committed to fairness and may see an initiative that appears to favor one group of physicians over another as unfair.
What are some other ways we might use the compact?
A compact can be a great benefit in managing a group. When shared with recruits in the hiring or acquisition process, it clarifies expectations for the new physicians. When shared among the current physicians, it provides guidelines for making difficult decisions regarding group strategy and individual performance.
What impact does developing a compact have on relationships between administrators and practicing physicians?
Beyond the benefit of the compact itself is the process of developing the compact. This should be done collaboratively by group leaders reaching out to all physicians, hearing their thoughts and feelings about the organization's values and how they apply in real life situations. The discussions themselves engage physicians across the entire group in what it means to be a member of the organization. Often, this is the first time that fellow group members have thought collectively about such issues. Physicians become engaged and aligned. The group is almost always much stronger as a result, providing a solid foundation upon which the group can build successfully.
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.
Building bridges of trust between practicing physicians and administrators reduces burnout and improves well-being.
As trust grows, the organization functions more effectively, adapts more quickly to changes in the health care landscape, and is better able to deliver on its mission of providing excellent patient care and serving the community.
Journal Articles and Other Publications
* Kornacki MJ, Silversin JB. A New Compact: Aligning Physician-Organization Expectations to Transform Patient Care. Health Administration Press; 2015.
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