The Physician Executive by Steve Fasnacht

March/April 2009 • Vol. 35 Issue 2

inside 16 Cornerstone Health Care: From Paper to Digital in Record Time 20 Going All Digital is Easier Said Than Done

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Contents MARCH • APRIL 2009, VOLUME 35 ISSUE #2

features 2009 ACPE Health Care Technology Survey President

Cynthia S. Sherry MD, MMM, FACR, CPE, FACPE

Carrie Weimar

Chief Executive Officer

Examine the results of the ACPE's 2009 Health Care Technology Survey and find out why some physicians are very skeptical of all the promises made by IT supporters.

Barry R. Silbaugh MD, MS, FACPE

Editor Bill Steiger bsteiger@acpe.org

Art Director

Health Care Technology 16

Jill H. Fasnacht Steve A. Fasnacht

A physician executive explains how her group practice dove into digital communication and left the paper world behind.

Debi Marsh

Tina Ramsey phone: 800-562-8088 tramsey@acpe.org

Explore the ups and downs of implementation as a heart hospital tries to go totally electronic.

Member Essay 24

Take a look at two problems facing health care organizations that haven't been adequately addressed.

(Below is a partial listing of our 80-member review panel.)

Decision Making

Ethical Issues

Financial Issues Hugh Long, MBA, JD, PhD Mr. Mark Covaleski, CPA, PhD

Health Law Susan Lapenta, JD Alice Gosfield, JD Todd Sagin, MD, JD, CPE Henry Casale, JD

PEJ MARCH•APRIL/2009

Elephants Under The Table Richard M. Lauve, MD, MBA, CPE, FACPE

ACPE Editorial Review Panel

Jeremy Sugarman, MD, MPH, MA, FACP Shattuck Hartwell, MD, FACPE Mr. Laurence McCullough, PhD

Going All-Digital is Easier Said Than Done Carrie Weimar

Advertising Representative Jan Mason MediaRep Consultants 773-325-1804 Medrepcons@aol.com

Cornerstone Health Care: From Paper to Digital in Record Time Grace Emerson Terrell, MD, MMM, CPE, FACP, FACPE and Tim Terrell

Production and Design Coordinator Advertising Department Director of Advertising

Electronic Health Care Advances, Physician Frustration Grows

Does Your Organization Have DRIVE? Niranjan Kissoon, MD, CPE, FACPE, Bradley J. Campbell, MHSA and Nash Syed, MBA

Take a look at a decision-making process where all the roles and responsibilities for making decisions are clearly defined.

features Op-ed 34

Pay-for-Performance Hit or Myth?

Management Education 40

Medical Leaders Wanted—Business Degree Desirable

Alan P. Marco, MD, MMM, CPE, FACPE

Arthur Lazarus, MD, MBA, CPE, FACPE

Why It Won't Work

Increasingly, the phrase “business degree desirable” is appended to classified advertising geared toward physician executives.

Kent Bottles, MD

Two physicians offer theories and insights on why P4P doesn't work as well as many had hoped.

Recruiting 44

The Search for Effective Physician Leaders: New Strategies for New Challenges Kurt Scott

Examine a complete recruiting and interviewing process that you can follow when you're looking to hire physician leaders.

columns Compensation 70

Physician Executives Beware: Your Pay May Be Reported

Careers 74

Are You Considered A “High Potential?” Bill Tiffan

David Bjork, PhD

Leadership Ethical Aspects 72

Hospital Chaplains: What, Who, and Why?

Do You Have CEO Disease? Manya Arond-Thomas, MD

Richard E. Thompson, MD

departments 4 82

Letters to the editor ACPE News

ISSN: 0898-2759 Published bi-monthly for members of the American College of Physician Executives. Any reproduction without permission is prohibited by law. Annual subscription rate is $80 ($96 outside the U.S.). Copyright ©2009 by the American College of Physician Executives, Two 400 North Ashley Drive., Suite 400, Tampa, Florida 33602, (813)287-2000. Physician Executive is indexed in the American Hospital Association’s Hospital and Health Administration Index and in the National Library of Medicine’s PubMed, www.pubmed.gov, and in the ABI/Inform database by ProQuest.

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Accreditation The American College of Physician Executives (ACPE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing education for physicians. Designation The American College of Physician Executives (ACPE) designates these educational activities as AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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12/22/08 12:48:17 PM

Our Emergency Department One Year Later “If You Build It, They Will Come! The First Six Months in a New Emergency Department,” was published in the Jan/ Feb 2009 issue of The Physician Executive, Vol. 35, Issue 1, but written several months earlier. Since then a lot has happened and I thought readers might like an update. In our first year of operation, we saw just over 74,000 patients, or about 11 percent above hospital projections. When I wrote my article, our volumes seemed relatively stable at about 202 patients per day, but summer hit and week 43 averaged 235 patients per day. By at least one measure, however, our 52nd week proved to be our best, with an overall average LOS at 185 minutes. As mentioned in the original article, door-to-doctor time (DDT) yo-yoed as we changed processes periodically in the first six months. But since we solved our staffing deficits (1.46 RN HPPV in September) we can now utilize the entire department at peak hours and DDT has steady improved. Our dedicated triage team is working a new process to cut our DDT in half. 4

PEJ MARCH•APRIL/2009

We also developed a focused audit and education program for nursing documentation. I predicted at the beginning of the year that we could increase relative value units (RVUs)/patient visit by 10 percent simply by monitoring this metric and with some basic education. In the first 10 months, we increased RVUs/pt by 10 percent and our net operating income per patient by 24 percent! As our reliance on outside agency nurses concludes at the end of this year, we predict further increases as a stable nursing staff continues to refine these skills. We are also encouraged by continued successes in physician productivity. We have ample opportunity to make our department more efficient, but one measure of productivity, patients/physician/ hour, has improved steadily since we opened. We initiated a six-month trial of productivity-based pay for physicians in Q3 2008, but there are too may variables at this point to conclude that the compensation model is responsible for these improvements. As we continue to collect data, we may be able to answer that question. Regardless of the answer, we plan to continue a multifaceted approach improved efficiency and to continue developing a patient-centered ED.

Jeff O'Driscoll, MD Utah Emergency Physicians Salt Lake City, UT

Y Not Zero I am a loyal reader of The Physician Executive, and have been a member/Fellow of ACPE for over 15 years. I have a brief but important comment to make on the article by Jeff O'Driscoll, MD, in the (Jan/Feb 2009, Vol. 35, Issue 1) journal, entitled "If

You Build It, They Will Come!" While the article is interesting and cogent, and I certainly appreciate its merits, in my opinion 10 of the 12 graphs exhibit a serious visual deficiency that often leads to bias. Only figures 6 and 11 have their y-axis starting at zero, so that the relative visual/ numerical comparisons between heights of x-values are balanced. Whenever the y-axis starts at any other point, the visual deception may significantly distort the actual, numerical comparisons, making things seem more (or less) significant than they really are. For example, try extending the y-axis in any of the other figures to zero; while it would take up more space, the differences obviously seem a lot less dramatic and appealing than they do in the current presentation. While I am aware that marketing is a hallmark of business, and business is a hallmark of medical management, above all we as physician executives must first stand by the values of science and evidence, and should always try to attain the highest, non-biased standards of visually presenting quantitative information. I believe the graphs in this article are a lesson to all who undertake or interpret research as to how not to present such information in a neutral, unbiased manner, since the visual impression of differences is actually more magnified than their numerical intensity. For further reference, see any of the 4 wonderful books by Edward Tufte, such as The Visual Display of Quantitative Information.

Attilio V. Granata, MD, MBA, CPE, FACP, FACPE Yale School of Medicine Orange, CT

'Bailout' for Primary Care? I congratulate Maureen Glabman on a thoughtful and thorough review of the problems facing primary care in the United States. (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) She mentions that the AAMC is suggesting increases in medical school graduates. However, it must be recognized that increasing the number of MD/DO graduates will only increase the number of practicing physicians if the number of postgraduate residency training positions are also increased. If resident slots are not increased, than training more U.S. graduates will just increase the competition for current slots, and probably make it more difficult for international graduates to find graduate residency training positions. Clearly CMS and the federal government have to buy into increasing the number of physicians being produced, and in these difficult financial times the enthusiasm for funding more resident slots is likely to be minimal. Perhaps the AAMC should consider obtaining a banking charter and then approach congress looking for a "bailout" to fund the needed residency positions.

William J. Mann, Jr., MD, MBA, FACOG, FACS Carilion GYN Oncology Associates Roanoke, VA

Residencies and Business Don't Mix We enjoyed the thoughtful and well written article “Why Primary Care Physicians Should be Self Employed.” (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) However, based on many years of experience with Ob-Gyn residents, we are pessimistic as to the success of your suggestion for two reasons. First, as we interview medical students for residency, it is clear that they strongly value lifestyle issues over financial concerns. These new graduates expect

compliance with 80-hour work weeks during their training (and we all suspect that 80 will soon be 60 or 65 hours). They expect child care, time off for CME, and time for personal relaxation. They strongly desire to focus only on caring for their patients and not on "administrative" issues. And when they are off, they want to be completely off—not worrying about financial or human resource issues. We used to be astonished by this attitude in light of the fact that many of them are facing educational loans in excess of $150,000. Second, during resident training, every hour is vital and important, and residents show little inclination to take time away from patient care to focus on business issues. They see little value in this non-clinical learning, and would prefer that others worry about these issues. A 2007 survey we conducted with program directors of Ob-Gyn residency programs in CREOG Region 2, it was reported that in 83 percent of programs, there were less than eight hours per year of dedicated curricular time allotted to the business of medicine. Teaching residents about coding, information technology, government law, practice management, and liability was not an educational priority. It is no surprise that residents completing their training seek positions after graduation in which the business side of medicine is taken care of for them. They focus on caring for their patients. Additionally, finding teaching faculty who are sufficiently knowledgeable about the business side of medicine in an academic environment is quite challenging. We believe a better approach is developing a cadre of physician executives who can employ and direct primary care physicians within a profitable business plan. Doctors employed by doctors.

Debra Gussman, MD, MBA Jersey Shore University Medical Center Neptune, NJ William J. Mann, Jr., MD, MBA, FACOG, FACS Carilion GYN Oncology Associates Roanoke, VA

Primary Care Needs to be Saved Having spent 14 years of my 25-year career in private solo practice, I thoroughly enjoyed reading your article “Why Primary Care Physicians Should be Self Employed.” (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) Until recent times, the delivery of medical care in small towns and all sorts of neighborhoods was the most successful cottage "industry" in this country. The struggle of running the business of private practice was immense. The rules for small businesses were overwhelming. Add to that the issues of employment, taxes, compliance, and wrestling with myriad third-party payers made it unfun. Residents coming out of training have mentors telling them that private practice is dead and not the way to go. So as much as I agree with what you have written, much needs to be done to restore the PCP in the community. This includes helping the practitioner run the business. If we don't see changes, I believe we will see only large megacenters of care; and if you live more than 15-20 miles from one, you have a problem.

William A. Sorber, MD, Ph.D Guthrie Corning Hospital Corning, NY

'Self-Employment' Not Realistic I have just read an excellent article by Maureen Glabman discussing some of the serious issues primary care physicians must manage today. (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) With a background in pathology and medical management, I presently chair Personalized Health Care (PHC) for the College of American Pathologists. This last October, I participated in the first National Summit on Personalized Health Care and one of many clear messages from the conference was that 21st Century medicine will be a highly integrated affair. An example is Patient Centered Medical Home, alluded to by Ms. Glabman. ACPE.ORG

Letters continued Now to my point: I find it a lack of editorial talent to publish the article by Ken Zonies, “Why Primary Care Physicians Should Be Self-Employed.” (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) I fear Dr. Zonies' view is not consistent with contemporary thought about today’s medicine, since evidence is that PHC is not to be denied. Molecular/genomic science and modern medical informatics will impose cost on the physician delivery system rarely supportable by independent private practices (e.g., EMR’s/EHR’s.) In my opinion PEJ should spend its well-read pages on forward thinking articles like Diane Shannon’s great interview with Mark Chassin, on the truly transformative change emerging science will have on the practice of medicine and delivery of health care. (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.)

Louis D. Wright, MD, FCAP, FACPE Senior Advisor, PSA/MED3000 Florence, SC

Fear Drives Residents Away from Primary Care I read with great interest Dr. Ken Zonies article entitled "Why Primary Care Physicians Should Be Self-Employed." (The Physician Executive, Vol. 35, Issue 1, Jan/Feb 2009.) As a family medicine residency director for the past decade, I have noted the marked trend of our graduates electing to become employed physicians rather than undertake private practice. This is despite the fact that we have a well-rounded practice management curriculum. Oddly enough, in contrast to Dr. Zonies' article, residents often tell me they believe there is greater flexibility and income as an employed physician versus one that is self-employed. I believe the primary reason that residents are not choosing private practice is fear. 6

PEJ MARCH•APRIL/2009

Many residents who do choose primary care specialties are well aware that they will not be compensated as well as their colleagues in other specialties. Therefore, they are fearful that they will not be able to pay their significant medical student debt. The median medical student debt in 2008 was approximately $145,000 for students at public medical schools and $180,000 for those at private medical schools.1 In fact, in many cases, students are forced to take additional private loans after they exceed the federal borrowing limit. This significant debt burden engenders risk-aversion among primary care residents and encourages them toward employed positions. If the current trend of escalating medical student debt continues,

the prospect of a primary care resident choosing self-employment is remote.

Richard R. Terry, DO, FACOFP Director, Wilson Family Medicine Residency Director, Osteopathic Medical Education Johnson City, NY 1.

Steinbrook, R (December 18, 2008) Medical Student Debt - Is There a Limit?, The New England Journal of Medicine, 25:359:2629-2632. (Accessed February 3, 2009 from http://content.nejm.org/cgi/content/ full/359/25/2629.)

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2009 ACPE Health Care Technology Survey

Electronic Health Care Advances, Physician Frustration Grows By Carrie Weimar

In this article… Five years have passed since ACPE's first Health Care Technology Survey, and while great strides are being made to implement information technology, physicians say they still feel out of the loop.

Now more than ever, we live our lives behind the screen of a computer. Need to pay some bills? Just go online and click a button. Many of us use computers to store our music collections or to watch movies or TV shows. We communicate via BlackBerry or Iphone and keep up with friends and colleagues through social networking sites like Linkedin or Facebook. When news breaks, we flood sites like cnn.com or nytimes.com. But for many physician executives, the digital revolution ends the moment they reach the office. Despite the enormous progress made in information technology, many hospitals and group practices still use the same paper charts physicians have been using for decades. In fact, according to a recent federal survey, just fewer than 40 percent of U.S. doctors use electronic medical records and many say the system they use is only minimally functional. In 2004, the American College of Physician Executives decided to answer the question of how prevalent the use of technology was among its members. The survey results revealed two different schools of thought: those who embraced technology and those who were unenthusiastic and resistant. The 2004 survey also showed that many health care organizations were slow to implement new measures. Only about 33 percent of respondents said they were already using electronic medical records. About the same percentage reported using computerized physician order entry (CPOE). And just 20 percent used pharmaceutical bar coding.

PEJ MARCH•APRIL/2009

Growth over 5 years Now, five years later, ACPE wanted to see how things have changed. So members were asked to participate in an identical survey to measure the different responses. The result? More health care organizations are using technology, but the same love/hate relationship exists among physicians. While many see an array of benefits, an even larger number said they found the available software frustrating and not very user-friendly. Many also saw a need for more physician input before technology is implemented. And some were discouraged by the tech-adverse attitudes of many of their colleagues. One physician summed it up like this: “The technology has advantages but it wastes time. It is difficult to review records. It is much easier to review a paper chart. In a high-volume practice, it costs time and lots of money.” According to the survey results, far more physicians are using technology compared to five years ago. More than 64 percent of the survey respondents said electronic medical records were already in use at their organizations. Another 44 percent said they used computerized physician order entry. Thirty-eight percent of those who responded to the survey are using pharmaceutical bar coding, while 42 percent have electronic prescriptions. A smaller number—about 19 percent—use email or other online means to communicate with patients. And about 34 percent use personal digital assistants for clinical use. When asked why they are using or planning to use health care information technology, respondents were split. • A slim majority—about 33 percent—said technology reduces liability and medical errors. • About 28 percent said it led to more accurate recordkeeping. • 21 percent said they were just trying to stay current.

Some participants who submitted their own answers said it was beyond their control, such as one who said, “No rational reason. The hospital simply wants to do it.” Another added, “Forced to do so by government authority.” A majority of survey participants—about 40 percent—listed a lack of money or resources as the biggest obstacle they faced in implementing new information technology. Another 20 percent said there was a lack of support or buy-in from physicians and other medical staff. About 12 percent said it was too difficult to integrate new technology with other computer systems they were already using. Those who offered their own answers listed a variety of hurdles, from “more complex than expected” to “slows work flow” to “our administrator hired an idiot for our Internet person.” The 2009 ACPE Health Care Technology survey was open from November 15 until December 20. About 950 ACPE members responded.

Frustrations mount While more physicians may be using technology than they were back in 2004, there is still a significant

divide between those who embrace the new systems and those who feel they are frustrating and unhelpful. Some of the participants were enthusiastic about the advances, saying that their organizations were faster, more efficient and offered higher quality care thanks to the new technology. “Health IT has enabled us to do a lot of standardization of health care quality initiatives,” one physician wrote. “In many respects, it has helped us to compel those who will otherwise not comply with these initiatives.” “I believe over the long term, it will streamline efficiency and reduce errors,” another wrote. Others were similarly positive in their comments:

years now, I feel I am more organized, complete, and consistently clear on my communication with patients. Sometimes the time doesn't exist to cover all the information about disease—but at the press of a button I can print all that I want to share and have the patient review at a less stressful time than in the office. Even as a patient I appreciate printed info from my doctor that allows me to review at another time.” But the enthusiasts were far outweighed by the skeptics. Just as in 2004, there was no shortage of complaints. One physician even went so far as to say that adopting electronic medical records has been “the worst aspect of my 25 years in medicine. It has ruined doctor productivity, produced lower quality care and encouraged notes that are false to the point of fraud.” Most of the complaints were very similar to those voiced five years ago. While the technology may be more advanced, it still prompted plenty of grumbling. The respondents said the systems were still too clunky, too hard to use and just too poorly developed.

• “It was painful to implement, but I wouldn't go back to the way it was. Access to information is much faster and better, communication with patients has improved, but there has been some degradation of the office visit documentation.” • “I love it. I can access my patients' charts from home or on vacation.” • “Since being on EMRS going on 4

Electronic Medical Records

2009 Response

Percent

Count

No development under way

5.9%

15.1%

237

Researching/Planning

17.5%

163

33.3%

521

Bidding

2.4%

4.5%

Testing

9.9%

14.0%

220

Already in use

64.5%

602

33.1%

518

934

1566

answered question skipped question

2004 Response Percent Count

ACPE.ORG

'Our administrator hired an idiot for our Internet person.' “We have experienced occasional difficulties with glitches in software not becoming apparent until after implementation,” a participant wrote. “It seems that once you put something into use by the medical staff, the hidden problems appear. An adequate pre-implementation testing environment has not been developed so that staff sometimes feels they are part of an ongoing experiment.” Others echoed those statements: • “The world is different but structures, shared systems, policies and management controls are still scoped for a paper world …. For the COO and the CFO, a big problem is the value proposition of electronic record keeping. Where are the costs offsets? Are there enough?” • “The technology out there is very poorly developed and generally causes as many problems as it solves—something that is rarely reported. An easy example: paper never has downtime. Our (technology) currently has to go down twice a year for the change in Daylight Savings Time! I truly believe tech is the answer to better patient care, but I strongly believe it should not be implemented without major input from people on the front lines.” • “Process has been long, expensive and time-consuming …. Software is clumsy and not user-friendly. The system has been implemented in only about half of clinics, and not in inpatient service …. It’s all very discouraging, especially to those of us who have been long-time advocates of EMR.”

PEJ MARCH•APRIL/2009

The cost—and the amount of staff resources needed to implement a new system—was also a common complaint. And given the recent downturn in the economy, physicians said they expect problems to get worse instead of better. • “Major constraints are resources and expertise. Good systems and system implementation are hugely expensive. Few organizations have adequate project management skills or processes, let alone IT and clinical work flow expertise. Consulting organizations can do all of this, but are themselves hugely expensive and are being stretched to accomplish the work they’ve already taken on.” • “Cost is prohibitive and in the new credit/capital crunch we are in, I suspect further roll-outs to be delayed, which will leave us in a bad spot: half in and half out of EMR so we have paper charts and electronic records. It’s the worst of both worlds.” • “Apart from costs of hardware and software, there is a tremendous cost in staff time and revenue when switching from paper to electronic charts. This is especially true when there are decades of medical records to convert.” Many ACPE members also said that the available systems don’t do a good job of talking to one another. The exasperation was especially acute among doctors who travel between hospitals and group practices. Many said a universal system is needed so that different institutions can share information. “To this date, there has been a lack of incentive to collaborate in the

use of health care technology,” one participant wrote. “Each organization uses its own information to maximize its advantage, leading to many pools of information that ultimately are difficult, if not impossible, to use together.” Another expressed a similar sentiment: “We are at the mercy of multiple vendors and lack of standardization, without extra capital to spare. This is a no-win situation and results are mixed, or certainly less than impressive in regard to the enhancement of quality.”

No input in output Perhaps the biggest source of frustration was the lack of input from physicians when designing and implementing health care information technology systems. Many said that involving clinicians at the planning stages would pre-empt many of the problems that crop up later. As one respondent put it, “there seems to be too little physician involvement in planning. There is no well-thought-out plan of how technology can be utilized to optimize workflow or improve efficiency. Systems are chosen according to administrative criteria rather than what physicians need to get the job done.” Another grumbled that physicians are being coerced by “non-practicing physicians and non-medical administrators who forget that time spent with patients is more important than spending 90 percent of the time filling out paperwork so the beancounters can look over your shoulder.” Among the other similar complaints: • “It’s difficult to keep IT interested in the discussion. They don’t take the time to really understand the problem and want us to adapt to whatever software they come up with.”

Computerized Physician Order Entry (CPOE)

2009 Response

2004 Response

Percent

Count

No development under way

13.7%

127

22.4%

349

Researching/Planning

26.2%

243

33.8%

527

Bidding

2.5%

4.6%

Testing

13.9%

129

15.8%

247

Already in use

43.8%

407

23.3%

364

answered question

929

1,560

skipped question

Percent Count

Pharmaceutical Bar Coding

2009 Response

2004 Response

Percent

Count

No development under way

30.6%

277

36.7%

559

Researching/Planning

20.7%

187

31.4%

479

Bidding

1.7%

2.8%

Testing

8.6%

8.3%

126

Already in use

38.4%

347

20.7%

316

answered question

904

1,525

skipped question

Percent Count

Electronic Prescriptions

2009 Response

2004 Response

Percent

Count

No development under way

15.0%

139

34.0%

524

Researching/Planning

27.1%

250

33.7%

518

Bidding

2.8%

1.9%

Testing

12.9%

119

9.4%

145

Already in use

42.2%

390

20.9%

322

answered question

924

1,539

skipped question

Percent Count

ACPE.ORG

Some predict a paper chart will one day be as antiquated as a mercury thermometer.

Patient Electronic Communication (including patient e-mail and online patient communication)

2009 Response

2004 Response

Percent

Count

No development under way

38.8%

359

44.0%

680

Researching/Planning

30.2%

280

28.2%

437

Bidding

0.8%

Testing

10.6%

8.7%

134

Already in use

19.7%

182

18.2%

282

answered question

926

1,547

skipped question

Percent Count

Personal Digital Assistants (PDAs) for Clinical Use

2009 Response

Percent

Count

No development under way

42.2%

388

27.3%

421

Researching/Planning

16.1%

148

24.8%

383

Bidding

0.8%

1.3%

Testing

7.3%

10.2%

158

Already in use

33.7%

310

36.2%

559

answered question

920

1,543

skipped question

PEJ MARCHâ&#x20AC;˘APRIL/2009

2004 Response Percent Count

In general, what is the PRIMARY reason why you currently use or plan to implement new health care information technologies.

2009 Response

Percent

Count

2004 Response Percent Count

Wave of the future, trying to stay current

21.2%

194

11.1%

167

Reduced liability and reduced medical errors

32.9%

301

42.5%

638

Accurate recordkeeping

28.1%

257

28.7%

431

High return on investment

3.6%

6.3%

Other (please specify)

14.1%

129

11.3%

170

answered question

914

1,501

skipped question

What is the PRIMARY obstacle that your organization encounters when implementing or attempting to implement -- new information technologies.

2009 Response

Lack of support or buy-in from physicians and other medical staff

Percent 19.6%

Count 178

Too difficult to train staff to use technology

4.1%

3.4%

Lack of money/resources to implement technology

40.9%

372

45.9%

685

Little or no return on investment

6.5%

4.0%

Too difficult to integrate with computer systems already in use

11.9%

108

13.8%

206

Havenâ&#x20AC;&#x2122;t seen the right system yet

4.3%

7.0%

105

Other (please specify)

12.8%

116

8.0%

119

answered question skipped question

909 26

1,494 87

2004 Response Percent Count 17.9% 267

ACPE.ORG

• “The biggest issue is not necessarily the physician resistance—it is the administrative resistance to admitting that these are not just IT projects. They are clinical projects, just as any other process change in clinical care would be viewed.” • “There has been little attempt to train physicians so they can use the system well. The interface between the physician and software program is cumbersome. Rather than interface the main system with a documentation system that has a proven record in emergency departments, they are using a system that the docs don’t like. Pound foolish!” • “Physicians must be at the table as technology is incorporated. The institution must be fully committed. Ready support for recognized issues must be available.”

Of course, not every physician is excited by the prospect of switching from a paper chart to an EMR, no matter how much input they are allowed to give. Several participants wrote in to complain about their technophobe colleagues, who they say are blocking progress for the rest of their colleagues.

implementation tooth and nail. Do they think we have any choice about EMR adoption, or that they, uniquely, can ignore the trend?”

Digital divide So why, at a time when so many other businesses have already gone digital, is the health care industry still fraught with so many problems? Albert Villarin, MD, FACPE, chief medical information officer for Albert Einstein Healthcare Network in Philadelphia, Pa., said cost is a major factor. “Many institutions can’t afford to buy the level of quality and integrity with a global system for an entire network,” said Villarin, who also writes a blog on health care technology. “We’re talking hundreds of millions of dollars in a large market.” Because there aren’t very many universal systems that meet all the different needs of a typical health care

• “Don’t underestimate your partners’ anxiety in changing their comfortable ways of getting through the day. Promises of efficiency only come after hours of suffering. ‘It ain’t easy, but who said it should be simple?’” • “Some physicians embrace IT and others shun it, causing hospitals to avoid adoption due to fears of alienating older medical staff.” • “Some physicians—young ones included—fight the process of

Where does your organization stand when it comes to physician involvement in health care technology decision making?

2009 Response

Physicians have little or no involvement in technology decisions

Percent 16.6%

Count 152

2004 Response Percent Count 21.0% 315

One physician works part-time on technology issues

31.9%

292

28.8%

432

Full-time physician technology officer

12.2%

112

10.3%

154

More than 1 full-time physician working on technology

20.7%

189

18.7%

280

Other (please specify)

18.6%

170

21.2%

318

answered question skipped question

915 20

1,500 81

PEJ MARCH•APRIL/2009

network, many organizations try to cobble together “best of breed” platforms and try to make them communicate with one another, Villarin said. For example, a computer system that best fits an emergency department may not be compatible with a system geared toward palliative care. A smarter approach would be to look at an institution as a whole and try to design a system that will best serve all departments, Villarin said. That’s what his network did when deciding how to implement technology. “There was a team of 20 people from all different areas—clinical, support and research. We sat at a table and made the product the way we wanted it to be,” Villarin said. “You have to take a network and hold up a mirror and understand what you’re looking at.”

While the number of suitable options for health care systems is increasing, Villarin said he doesn’t expect to see much progress over the next five to seven years. The reason? Cost. With the economy in a slump, there’s little chance that a network or hospital is going to spend the money necessary to make sweeping change. Still, most of those who participated in the survey—believers and non-believers alike—said that health care will someday succumb to the same forces driving other industries and make the switch to digital. Some predict a paper chart will one day be as antiquated as a mercury thermometer. One member likened implementing the computer system to ordering a sleek Corvette and being delivered a box filled with Corvette parts. But he still expressed hope for the future.

“I feel like I hit a cliff head on and have been dragging myself to the top,” the physician wrote. “But after 10 months, I can see the promised land.” Or, as one physician summed it up: “It’s expensive, difficult and essential. We would never go back. The trick is using the technology to improve the process. We’re still and will always be working on that.”

Carrie Weimar Director of public relations at the American College of Physician Executives. cweimar@acpe.org

ACPE.ORG

Health Care Technology

Cornerstone Health Care: From Paper to Digital in Record Time By Grace Emerson Terrell, MD, MMM, CPE, FACP, FACPE, and Tim Terrell

In this article... Learn how a North Carolina practice went completely electronic is a very short time, with physicians leading the charge.

Tomorrow night I’m on call for my internal medicine practice. If I am needed, the answering service will send me a text message on my mobile smart phone, where I have wirelessly updated the most recent meds, vital signs, labs, allergies, admission notes, consults, imaging studies, and orders on all the patients on our hospital inpatient census list. When I call the nurse at the hospital back, this information is at my fingertips. If I am uncertain about a particular medication or course of action, I can query Epocrates® or UpToDate® through the same small mobile device. If this information is inadequate, I can move to my laptop and query the hospital’s electronic clinical portal system directly to view old hospital medical records. Alternatively, I may enter the patient’s outpatient electronic health record to view all of the events that led up to the current hospitalization from any of the physicians’ practices the patient may have seen in our multispecialty group. I have access to this same rich outpatient data when I round at the hospital the next morning, as did the emergency department physicians and hospitalists who evaluated and managed my patients prior to me assuming their care. At discharge, the patient’s prescription will be sent electronically to his or her pharmacy of choice, automatically performing drug reconciliation in the outpatient medical record in the process.

Quick turnaround Wow! How did we get here so fast? Ten years ago I had never used a computer for much more than word-processing. Five years ago, my practice was entirely in the paper world. 16

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Three years ago, I still wrote paper prescriptions. The privacy-protecting, encrypted electronic information I use to practice medicine in 2009 empowers my colleagues and me to practice safer, more efficient, higher quality medicine. I began my private medical practice 16 years ago. I would never go back to those “bad old days.” It is with total astonishment therefore that I read DesRoches et al’s July 2008 article in the New England Journal of Medicine reporting that only four percent of physicians currently have a fully functioning electronic record system in the ambulatory care setting nationwide and only 13 percent have a “basic system.” In 2004 the American College of Physician Executives surveyed its members about their use of health care technology. Among ACPE members surveyed, a third reported they represented health care organizations that had adopted electronic medical records and/or PDAs for clinical applications. Whether these applications represented a fully functioning electronic record system is unclear. What is clear is that Cornerstone Health Care, the multispecialty group in High Point, N.C., where I practice is part of the four percent minority that has successfully implemented a fully functional electronic record. The story of how we did this may offer a good case study for those seeking to understand those elements that lead to a successful adoption of technological solutions in health care organizations. Cornerstone Health Care was founded in 1995 when 16 separate practices merged to form a multispecialty group practice. Originally the organization had 42 shareholder physicians, 225 employees, and $16 million in annual net revenue. Fourteen years later the organization has grown to 235 providers with 133 shareholder physicians, and 1,300 employees and is one of the largest and fastest growing businesses in the Piedmont Triad region of North Carolina. It has increased its annual net revenues by more than ten-fold. Cornerstone currently has physicians on staff at six separate hospitals that are part of four separate health systems. Intrinsic to our successful growth has been our focus

on information systems infrastructure development, including our fully integrated electronic health record.

Physician leadership is key So how did we do it? Cornerstoneâ&#x20AC;&#x2122;s first five years established the culture that has engendered our subsequent success. We are physician-owned and physician-led. A board of directors of 12 physicians is elected by the shareholders and is responsible for the policy and direction of the company. From its inception this board has proactively sought to improve the practice of medicine by emphasizing clinical autonomy, patient-focused health care delivery, and pro-active innovation simultaneously. We permitted and encouraged individual innovation while simultaneously focused resources on those endeavors that would be the most beneficial to the physician group as a whole. Within this context, the board of directors began discussing the concept of a group-wide electronic medical record as early as 1998. In 2001 the board instructed the chief information officer to query the physicians regarding their desire to proceed with the development of an electronic medical record. The results were telling: 75 percent of the physicians desired EMR implementation within two years; the chief reason they gave for moving forward was improving patient care. The key principles for our implementation were to make adoption mandatory, to apply the right amount of human resources to be successful, and to become paperless as quickly as possible. In our discussions with vendors, other EMR adopters, and those whose EMR adoption had failed, we knew that you had to be completely successful to achieve return on investment (ROI). ROI could be achieved by creating efficient paperless systems that led to staff reductions, reducing/eliminating large costs such as transcription,

David Moore, MD

Keys to Successful EMR Implementation

As the chairman of the Cornerstone Health Care's EMR task force, David Moore, MD, spent a lot of time coaching physician colleagues during the implementation process. He says the keys to success are: 1. Highest level leadership is unwaveringly committed to EMR implementation.The implementation process is still too painful to assume that the perceived value gained will be enough to stimulate every member of the organization to voluntarily participate, so some level of mandated participation is still necessary to get the process started. 2. Implementation team is unwaveringly committed and passionate in undertaking the task and will do whatever is needed, within reason, to get it done. 3. Being a support team means 24/7 coverage, so there will be some infringement on each team memberâ&#x20AC;&#x2122;s personal life. 4. Compensation should be adequate to get the right people who are willing to commit to this level. 5. Focus on maximizing the technologyâ&#x20AC;&#x2122;s ability to improve quality of patient care. 6. Showcase functionality that facilitates provider performance and results in better patient outcomes. 7. Showcase functionality that facilitates improving safety of care. 8. Showcase functionality that facilitates using evidence-based medicine protocols. 9. Emphasize functionality that improves access to patient information and improves inter-provider communication and lessens wasted/ duplicate care.

continued on next page ACPE.ORG

We gave physicians lots of time to convert to electronic notes at their own pace 16 Keys to Successful EMR Implementation — continued 10. Work on functionality that allows comparison of performance or outcomes to national benchmarks. 11. Focus on maximizing the technology’s ability to deliver a return on investment. 12. Showcase functionality that improves efficiency and lessens expense. 13. Emphasize functionality that improves revenue production. 14. Be brutally honest in a constructive way in uncovering the deficiencies of the technology. 15. Be honest to your organization in portraying what the technology does not do well. 16. Identify the best workarounds until the product can be improved. This involves being intimately familiar with the functionality options available in the product as well as being open to exploring outside vendor options as add-ons. Be willing to make the effort to share these functionality deficits with the vendor for future product improvement.

David Moore, MD A practicing otorhinolaryngologist with High Point Ears, Nose, Throat, a Cornerstone Health Care practice. He chairs the EMR task force for Cornerstone, serves on the board of directors, and is chief of staff of High Point Regional Health System.

and by correct coding of claims. All these ROI elements require a full and successful implementation. Our board of directors' first action was to make adoption mandatory. The board discussed various physician needs and desires, risk management issues, and monetary issues. Organizational goals to be the best 18

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health care provider group in our market guided our board’s decision. The board felt that full adoption would be unifying and help us to reach our quality objectives. Most groups we had looked at had only one or two people assigned to their EMR implementation. We opted to hire five people and have since

expanded to seven people. All but two of these seven have direct clinical experience, including a nurse practitioner, a physician’s assistant, a nurse, and two medical assistants. Having clinical knowledge and experience on the team has been a critical element in many ways, such as developing note templates. More importantly, EMR adoption is about changing medical office workflows in radical new ways. Our clinical staff has been key to understanding these workflows and how to transform them in the right ways.

Going digital We decided from the start to scan all of our old paper charts. Scanning presented us with many challenges and we changed our approach radically when our first attempts did not work. We had a number of our physicians try to talk us out of this approach, arguing that it took too long and was expensive. Some asked for a modified approach where a small set of records were scanned. These efforts were rejected. Ultimately, there was no way to scan a partial chart without physicians feeling the chart was incomplete. We also felt that a partial electronic chart presented medical-malpractice dangers. Instead, we came up with a method of scanning each chart section as a single document. This approach allowed the physician to page through a chart section on screen quickly and easily and access all the records in reverse chronological order. We concentrated our scanning efforts ahead of a physician’s appointment schedule and created protocols that prevented new paper from getting into a paper chart that had already been scanned. Other keys to our implementation included beefing up our IT infrastructure to ensure that physicians would not be slowed down by network bandwidth. We added additional technicians as the number of computers

in the company grew. Our goals were to create very rapid turnaround time to resolve computer problems so that physician productivity was preserved and confidence in the electronic charts would increase. We implemented on tablet computers assuming that our goal should be to create a point-of-care environment. However, we concentrated on giving our doctors as much flexibility as possible on input methods, including typing, transcription, voice recognition, handwriting recognition, mouse, and stylus. We implemented whole offices all at once in order to establish electronic workflows quickly, but gave physicians lots of time to convert to electronic notes at their own pace. We also worked to make sure that the EMR was available from each physician’s home and from hospital settings. Our ability to focus resources and become paperless quickly helped achieve a strong return on investment. Transcription costs shrank to less than 1/5th of their pre-EMR amounts, or a savings of over $1,000,000 per year. Our approach to electronic notes allowed most of our doctors to become proficient without any loss of productivity. We have saved almost $100,000 per year on chart supplies, copy paper and toner. Our offices are more efficient and many have reduced the number of staff in their front office and back office areas. When asked, however, most of our physicians point to the intangible benefits. The rapid change to paperless workflows had many positive influences on our practice. We are achieving coordination of care in ways never believed possible. Our patients have a single electronic chart where they used to have a different paper chart at each physical location. Access to patient information is no longer limited by time and space. We are now exploring how to make patient information even more accessible on cellular devices that have taken

the place of PDAs. Follow-up surveys show that our doctors do believe that patient care has improved. The reasons why Cornerstone physicians are among the four percent of physicians to have fully functioning outpatient electronic medical records are many, but several reasons for our success are particularly relevant. Cornerstone is physician-owned and physician-led and we freely chose to implement the EMR, as opposed to having it forced upon us. The board mandated its implementation, but did so with flexibility and provided adequate resources. The culture of our organization allowed the EMR task force to change processes when necessary, without a lot of bureaucratic hurdles placed in the way. Physicians, mid-level providers, office managers, and other levels of staff were actively involved in the process from planning through implementation. Careful financial planning and return-on-investment analysis was done prior to implementation. Most importantly, we never lost our focus that the purpose of the EMR was to help us provide better medical care, and that, indeed, has been our experience. As greater numbers of physicians join us in embracing the new technologies we believe that will be their experience, too.

References 1.

DesRoches CM, and others. Electronic Health Records in Ambulatory Care –A National Survey of Physicians N Engl J Med. 2008: 359(1): 50-60, July 3, 2008.

Weber DO. Survey Reveals Physicians’ Love/Hate Relationship with Technology The Physician Executive, 32(2): 4-10, March April 2006

Hillestad R, Begelow J, Bower A, and others. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Aff (Millwood). 24(5): 1103-17, Sept-Oct 2005.

Virapongse A, Bates DW, and others. Electronic Health Records and Malpractice Claims in Office Practice Arch Intern Med 168(21): 2362-Nov. 24, 2008.

Grace E. Terrell MD, MMM, CPE, FACP, FACPE

Chief executive officer of Cornerstone Health Care. She serves on the board of directors of High Point Regional Health System and chairs its board quality committee. She also serves on the board of directors of the American College of Physician Executives. GraceTerrell@cornerstonehealthcare.com

Tim Terrell MA, MS

Chief information officer for Cornerstone Health Care.

ACPE.ORG

Health Care Technology

Going All-Digital is Easier Said Than Done By Carrie Weimar

In this article… Deciding to build an all-digital heart hospital was easy; implementing all that technology and making it work continues to be a challenge.

The plan was ambitious, but it seemed straightforward— at least at the start. Pepin Heart Hospital, a 125-bed facility on the campus of University Community Hospital in Tampa, Fla., was expected to be nearly paperless when it opened to patients in February of 2006. Computers lining the hallway near the patient rooms would allow doctors to check records or view X-rays and diagnostic tests. Patients could use bedside computer screens to check email or watch videos relating to their treatment. Updates on patient care would be sent automatically via email to primary care physicians or nursing facilities. But today, despite careful planning and the input of a bevy of experts, Pepin is still at least a year away from being fully digitized. Some significant progress has been made. The hospital now has fully operational nursing documentation and integrated patient care monitoring devices in the operating rooms. But there have also been some notable setbacks from both an operational and an institutional standpoint. The hospital still hasn’t reached its goal of implementing electronic medication administration (eMAR) or computerized physician order entry (CPOE). “It’s a lot harder than just pressing a button,” said Brigette Shaw, Pepin’s chief executive officer. “There’s a lot of coordination and expense involved.” But in many ways, the obstacles the hospital faced in trying to implement a paperless system illustrate why health care organizations across the country have been slow to adopt new technology. 20

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From the problems they had convincing engineers to view things from a clinician’s point of view, to the reluctance of many doctors to adapt, to the difficulty of keeping up with new and rapidly changing technology, the journey to becoming a fully digitized hospital can be fraught with pitfalls. But Shaw, and others at Pepin, say the troubles they’ve experienced will be more than worth it once they reach their goal. “This is what you need to do to compete in today’s marketplace,” Shaw said. “We had to start looking at things in a different way.”

Starbucks and style Walking into Pepin, visitors may think they’ve stumbled into a boutique hotel instead of a cutting-edge cardiovascular hospital. Dark wood paneling creates a sense of comfort. Colorful works of abstract art line the walls. The two-story main entrance also features an open staircase and a textured water wall. The leather chairs in the lobby are soft and deep. There’s a small snack bar, dubbed the “Heart Rock Café,” that serves Starbucks coffee and muffins. In back, there’s a serenity garden featuring lush landscaping and a waterfall. The facility is intended to be a first-rate cardiovascular hospital, with a 52-bed interventional unit, 16 critical care beds, a 20-bed surgery recovery unit, 48 progressive care beds and five surgical suites. Pepin was designed with patient privacy in mind, Shaw said. All of the public areas, including waiting rooms, are on one side of the hospital, while all of the patient rooms are on another. This was done to help preserve patients’ dignity and comfort, Shaw said. Hospital officials also knew early on that they wanted Pepin to be almost totally paperless. Everything from pharmacy to nursing to registration would be done on computer. The thinking behind this was obvious, said Charles Lamberdt, MD, PhD, MBA, Pepin’s medical director. “It’s the future,” Lamberdt said. “It’s where everything else is going.” Technology has many obvious benefits. Supporters say

EMRs help improve reliability and decrease the possibility of error. Digital check-in systems are quicker and more convenient for patients, administrators and care-givers alike. Technology has been shown to boost productivity and streamline operations. It helps drive down malpractice costs and reduces the need for expensive transcription. Also, as one of Tampa Bay’s newest hospitals, Pepin's use of technology could help distinguish it from competitors, Shaw said. But developers knew it wasn’t going to be cheap. In fact, the total cost is expected to be about $35 million over five years. “It’s a huge, huge transition,” said Shaw. “More and more people are putting it on the docket, but it’s a very capital-dependent project. You need both money and intellectual capital.”

Partnerships and buy-in The hospital forged ahead by creating a partnership with GE Centricity, one of the more well-known providers of EMR technology. They also hired Lamberdt, who previously served as director of interventional cardiology at the University of Florida and Shands Hospital. One of Lamberdt’s key duties was to serve as a link between the technology providers and the hospital’s clinicians. He knew that creating buy-in among doctors was one of the most significant hurdles the hospital had to cross. He also had to convince GE’s engineers to tailor their technology to meet the needs of Pepin’s employees. “There’s really not a perfect hospital EMR,” Lamberdt said. “There are always going to be issues if top-down decisions are made for clinicians by non-clinicians.” Pepin also recruited Christy Kindler to be the director of clinical informatics. Kindler, a registered nurse, came from Indiana Heart Hospital in Indianapolis, which was one of the first in the country to implement an all-digital system.

Pepin Heart Hospital, Tampa, Florida Kindler had seen up-close the benefits of using technology and was excited to see them replicated in a new location. “Everyone wants the same thing,” Kindler said. “Everyone wants to take phenomenal care of their patients. And technology can be a really useful tool.” Everything was in place. What could possibly go wrong?

A wrench in the works No sooner had Pepin officials embarked on their ambitious endeavor when GE threw an 11th-hour wrench in their plans. GE acquired another company and decided to change its entire operating platform. That meant Pepin

had to start over from the beginning. Shaw said that wasn’t the only hiccup they encountered. Despite their best efforts, they had difficulty getting some of the doctors to accept the new technology. “It’s a mixed bag,” she said. “I think there are a lot of people who are always going to resist.” Hospital officials did their best to circumvent any problems by bringing GE engineers to Pepin and walking them through a typical day for doctors and nurses. The experience was enlightening, and they discovered a big gap in perceptions between the physicians and the technology providers.

ACPE.ORG

For example, the GE representatives were pleased when they cut the time to log in to the computers to 45 seconds. But for doctors, who have to log in to the computer 30 or 40 times a day, it took way too long. “They can’t appreciate the challenges until they’ve walked in their shoes,” Candler said. “Maybe not literally but at least figuratively.” They discovered other problems. Shaw said they quickly realized they needed to include the other organizations in the University Community Hospital (UCH) system in their digital systems. Because so many of their physicians shuttle between Pepin and UCH, not having a unified system made communication troublesome. So, moving forward, they are looking to broaden the scope of the project, Shaw said. Another snag: the computer screens they bought for patients’ bedsides are too small to be used as work stations. At just 11 inches, it was too difficult for doctors and nurses to key in information. Also, the UK-based company that manufactures and repairs the units stopped operating in the United States. But Candler said they have located another company that will be able to perform maintenance. And the bedside computers are very popular with patients.

TVs and Web cams Despite the setbacks, tremendous progress has been made. Large, flat screen TVs adorn the walls of the waiting rooms. Web cameras hang in the operating suites, allowing physicians to log in and watch surgery. Doctors can even contact colleagues to ask them to weigh in on a consultation. The new digital system also allows physicians to instantly upload EKGs, X-rays and other important documents. So far, one of the most popular features has been the clinical documentation system, which automatically records patients’ vital signs. Under the 22

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new system, nurses use a personal digital assistant with bar code technology. Nurses say the new system frees them to focus more on direct care, rather than spending so much time gathering and documenting a patient’s pulse, temperature and blood pressure. The new system is especially helpful if a patient is experiencing distress, said Susan Ruszin, staff nurse in the CSU. Instead of wasting valuable time recording vital signs, she said she can focus on the patient’s immediate needs. “This way I can concentrate on taking care of my patients,” Ruszin said. “It saves so much time and it’s so much more reliable.” The new system is already making a difference, according to two recent studies conducted by Pepin officials. The first was a time-in-motion study that measured six categories of nurse work behavior in a progressive cardiac unit. The nurses were observed before the electronic health record was implemented and then again a year later. What the researchers found was a marked increase in the amount of time nurses devoted to direct care after the electronic system was in place. The researchers attributed that to a significant decrease in time spent on administrative tasks—a 12 percent drop overall. The second study was performed to see whether the new electronic system was more accurate than traditional methods of recording vital signs. First, the researchers conducted a baseline study and determined the error rate for vital signs captured on paper then entered onto a paper chart or electronic medical record was 10 percent and 4.4 percent, respectively. Then the researchers conducted the study again using the personal digital assistants to capture the vital signs. After reviewing more than 1,154 samples, they determined the error rate to be less than one percent. Results like these prove that technology is a valuable investment, said

Shaw. She said she’s grateful that Pepin has already budgeted the money for the digital conversion, especially in light of the recent economic downturn. For Lambert, the embrace of technology is inevitable in the health care industry. As he noted, every other major field is already digital. In fact, the only segment of health care that is currently electronic is billing, and that’s because it’s required by the federal government. But the government can’t force the rest of the industry to adapt, Lambert said. “How are you going to do that in this economy?” Lambert asked. “Require every hospital to invest $30 million?” Pepin has already become an example for others around the country and even the world. Visitors have come from as far away as Dubai, India, Japan and Qatar to view the hospital and solicit advice from administrators. Shaw said she tells them to plan ahead. And no matter what, always remain patient. “Hospitals are like big ships,” she said. “They don’t change overnight.”

Carrie Weimar Director of public relations at the American College of Physician Executives. cweimar@acpe.org

ACPE.ORG

Member Essay

Elephants Under the Table By Richard M. Lauve, MD, MBA, CPE, FACPE

In this article… Lack of management knowledge and oversupply of physicians are two of the "elephants" that hospitals and group practices must confront.

There are aspects of the challenges to health care that have been only superficially addressed, or completely ignored, by the recurring health care reform debate made so visible during an election year. Everyone knows the issues are there, but they are not fully acknowledged. They are “elephants under the table.” Two of these elephants are so fundamental to securing improvement that they can no longer be ignored, and these two are completely, or nearly so, under the control of hospitals and/or physician groups to address.

The knowledge elephant Hospitals cannot make the quality and efficiency improvements that will be required to bring greater value to the U.S. health care system without informed participation by physicians. The successful models of high-value delivery in this country have one characteristic common to them all— informed and engaged physicians. But most physicians in this country are uninformed about health care finance, accounting, quality improvement 24

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methods, general management or leadership theories, and more. Yet these participants are highly educated (in their fields) and intelligent people, unlikely to subjugate their own perspectives to others. Where they are not brought into the decision process, they predictably “…either balk at the decisions made or have to be dragooned by organized misinformation backed by brute force.”1 There are efforts to engage physicians, improve communication with practicing physicians, and seek engagement in decision making, but all too often without providing basic education. The danger of this path is that a physician on a physician-administrative council, or similar body, without basic management knowledge actually participates in decision making. Without preparation for the task, physicians are destined to a perspective dominated by their particular clinical specialty, patient population, and perceived unmet needs within that silo. The dilemma of needing to communicate with an uninformed group was probably first described by Plato in the

allegory referred to as “Plato’s Cave.” Plato posited the question, “How do you relate to a group the importance of a particular set of information, when they have no basis for understanding the information or even a basis for understanding why the information should be considered?” This lack of knowledge or education, skills, and perspective—the unawareness of something, often of something important—has a treatment, and the therapy of choice is education. The condition is not the fault of physicians anymore than breast cancer is the fault of the woman. The majority of physicians in the United States were educated during a period when there was considered no time, space, or reason to include business topics in the curriculum of pre-medical or medical students. The changing environment of modern practice has been noted, and there are many educational offerings to meet the emerging needs of the modern physician who chooses to be more than “just a physician,” words I first heard from Lee Kaiser in the late 1980s. There are now 50 combined MD-MBA programs in the United States.2 We can expect, at some point in the future, the availability of informed physicians to be greatly increased. But the dual degree is not the best path for all physicians, and it would certainly not be very efficient for the majority of physicians already in practice to return to business school.

The doctor/king elephant There is a time-honored mantra of provider systems administrations: “No administrator ever admitted a patient. We need doctors and their good will to survive. Don’t do anything to upset the doctors.” But most large hospitals in the U.S., and some large groups, have more physicians than they now need. Without criteria to close a specialty or department of the medical staff to new applicants, many large metropolitan

Everyone knows the issues are there, but they are not fully acknowledged. They are “elephants under the table.” hospitals have two to five times more physicians “on staff” than actually admit or consult on a regular basis, and they accept more every month. Try this simple test. Compare how many physicians admitted 80 percent of the patients in your hospital last year to how many are on your medical staff. Try to include outpatient procedures in your “admits.” If the disparity is large, the difference is not solely because of consultants. Some of the excess will be physicians starting a practice and as yet not capturing inpatient services. We may need to give them some time and assistance. Some of the physicians who admit irregularly believe they must have privileges in multiple hospitals in order to capture patients with preferences, or whose insurance coverage requires certain facilities for maximum benefits of insurance coverage, unwittingly empowering the insurance companies. We might consider giving them another strategy for dealing with that challenge. Some of the “extra” physicians may be weekend coverage people from a large group. What better way to promote inefficiency and error than allowing a physician to work one weekend a year covering a large admitted population? Some of those physicians apparently not utilizing your facility and yet “on-staff” will be hospital shoppers, happy to play one hospital off the other, shuffling admissions to the hospital that is most “doctor friendly” this week. The last two groups are great formulas for destroying caregiver-team trust and mutual understanding of

system limitations. And they make it impossible to establish protocols and policies with an expectation of adherence. While there are a minimum number of physicians in most specialties needed for continuity of services and prevention of burn-out, beyond that number all the predictable problems of inter-group dynamics, politics, inefficiencies of scale, and other organizational behavior complexities overshadow any advantage from additional physicians. Yet few large hospitals have a medical staff development plan document that addresses oversupply. If we assume any improvement in efficiency from a shift to best practice, then most medium-to-large hospitals and many practices would function better with far fewer physicians in most service lines. The other face of this elephant is seen in hospitals more than one hour from a large city, some on the fringes of major metropolitan areas, and within some groups. In these organizations, there is a significant problem accessing enough high-quality doctors. In many, recruitment and retention of physicians is a primary financial concern of administration and their governing boards.3 While sometimes not consciously, these hospitals and physician groups are in conflict between a requirement to advance quality and efficiency, and the need to maintain service line availability to their population. This conflict is even more challenging to manage when existing compensation methodologies often emphasize procedurally based interventions over ACPE.ORG

Let the advantages of education separate the “way we’ve always done it” from the professionals committed to a lifetime of learning. those services of a purely cognitive nature. Indeed the financial survival of some institutions depends on the continuation of perhaps three service lines that fund the negative margins of all remaining services of the institution. The payment system in the United States heavily favors the specialties with procedural services. The purely cognitive services of the family practice, pediatric, and internal medicine physicians remain as severely under-valued as when first demon-

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strated by Dr. Hsiao in 1979. 4 There is a reason that physicianowned hospitals are dominated by the surgical specialties, and no accident that there is no plethora of new physician-owned psychiatric or pediatric hospitals. Lacking criteria for finding the best fit for an open slot, or financially pressured to take the first warm body that applies, small hospitals and groups can’t seem to get off the merrygo-round of recruiting the wrong person and then wringing their hands over how to handle the inefficient,

disruptive, uninformed physician. Both circumstances result from the lack of criteria, beyond specialty type, for selection of new physicians that would best meet their communities and facility needs. They are tangible manifestations of the underlying attitude toward the needed physician —“If only we could get another ‘X’.” These are but two faces of the elephant. We often treat physicians as the “rate-limiting-step” of a successful service line, ignoring the destruction possible when we recruit the wrong person. We assume that the physician is the key position in short supply, not realizing how the poor fit can dramatically decrease the supply of other key team members willing to work with the new recruit.

Elephant handling Strategies for handling both elephants have already been formulated

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and inculcated into the strategy of many of the high-performing systems in the country. It manifests itself in organizational policies toward new physician recruitment and selection, orientation of new arrivals, physician leadership development, and de-selection of existing physicians when necessary. Moving away from the current culture to one of mutual selectivity, mutual understanding, and high mutual expectations is not as difficult as it may sound. It requires sharing knowledge and sharing respect among the entire team (i.e., no “kings.”) To effect the culture change, the first step is recognizing and providing that body of material not included in the education of most physicians, yet critical for a physician to practice efficiently within a system. Implied in such knowledge is an awareness of the importance of the information for which the physician recognizes that he or she is not an expert. Further educational opportunities are provided later in the cultural transition for those physicians that choose to become more “expert-like” within any of the sub-topics of the material. These concepts are nothing more than current human resources management practices in better performing organizations from all industries. Compare those practices, often consuming three to 10 days of paid time in classrooms, to the typical one or two hours of orientation offered in most hospitals with voluntary medical staffs. Secondly, and more difficult for many systems, is to recognize that it is necessary for systems to pay physicians to acquire the knowledge that they don’t know they need. Because of the transactional basis of physician services, there is a real opportunity cost for them to attend educational programs. This combination of factors constructs a huge barrier to physician education—not knowing why they should go (how important the information is to them and their patients), 28

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and the cost of going. After such an orientation program, pay them to use that knowledge within the system. For those unaccustomed to such an approach, be assured that many systems have found methods both legal and with positive net-present values. But “what if you spend the time and money to educate physicians and they leave?” is an oft-heard and valid concern. The response has two parts: First, you may have less irrational competitors in the marketplace if they leave; and second, always consider the alternative, what if you don’t educate them and they stay?! The third step is implemented slowly and later in the cultural transformation—be more selective of who is allowed into your ranks, and who is allowed to stay. The right specialty to fill the slot is no longer enough to deliver high-value care. Hospitals must commit to working with a sub-group of individuals currently on staff. If dealing with the knowledge elephant requires hospitals (and groups) to provide more significant orientation for new members, and support for attendance and use of the knowledge gained, then this is probably an insurmountable task if you would not first select who you want to work with. Dealing with both of the elephants requires mutual selectivity. Many physician groups already do this after hiring, but selection criteria often lack a consideration of attitudes toward standardized policy and procedure, or other elements of organizational fit. Leave for last the de-selection process. Those who refuse education, or refuse to use that education, will be easily identified as inefficient, noncompliant with policy and procedure, disruptive in demands for services the system does not have, or lacking in quality performance. At first, let the advantages of education separate the “way we’ve always done it” from the professionals committed to a lifetime of learning.

Eventually, the lifetime learners will demand new standards for admission into, and retention by, the organization. That will be the time to consider new criteria such as: attitudes toward teams, required completion of orientation, new requirements for leadership eligibility, and a holistic approach to performance evaluation incorporated into retention decisions. The other half of the mutual selectivity concept in hospitals is physician commitment to a single system in exchange for “closed” service lines or medical staffs. Some hospital-based readers may question why a physician group would relinquish privileges at another hospital, but it is physicians who more readily embrace single-hospital allegiance as natural and necessary for them to be engaged with hospital operational improvements, where only they have certain privileges. They understandably insist on being paid for their efforts, and perhaps not so predictably, embrace education on topics they realize they need, to do well in their new roles.

Changing culture As I and others have argued for well over a decade, there are many causes of rising health care costs. Some are not in the control of the health care systems, but some are. Those of us within the health care system must refocus our attention on those elements we can control and cease the recriminations of others.5 This strategy is in our best interest and in the best interest of our patientcustomers. The alternative is to wait until “they” do what “they” can or should do to make changes in access, insurability, violent crime, drug addiction, disparities in the payment system, etc, etc. But what will be accomplished if all parties wait until “they” have done what “they” need to do? No, the answer to our problems will not come only from others. We must all address the issues within our sphere of influence as best we can.

Addressing all the issues at once with monumental change is rare when so many of the losers in any significant change (e.g., payment reform) are politically and financially well-positioned to fight the change. A distinction between “fiddling around the edges” vs. incremental change is an important one. If you are considering how to constrain your most inefficient orthopedic surgeon, you’re probably fiddling. If you are developing policy to identify best value delivery (quality and cost), incorporating those practices into a comprehensive care-delivery plan, and mandating adherence by a select group of orthopedists who are informed and participating in the construction of the plan, then you may be involved in a strategy to accomplish ongoing, reproducible, and recurrent incremental change. Many organizations have already adopted these concepts so that patients and insurance companies will prefer, because of documented better and more efficient care, a particular combination of hospital and physician. Many more are realizing that the health care landscape is changing around them. Pay-for-performance, quality reporting, ongoing and focused professional reviews by The Joint Commission, and new disruptive physician policy standards are but a few of the environmental shocks changing the health care industry and the professions within it. Careful selection accompanied by required acquisition of knowledge needed to achieve high performance, with thoughtful de-selection where necessary, of individuals who enjoy “closed staffs,” are two strategies we within health care can and should address. These strategies are not quick fixes, but they work.

References 1.

Cleveland H. The Knowledge ExecutiveLeadership in an Information Society, E.P. Dutton, New York, 1985.

AAMC data; See http://services. aamc.org/currdir/section3/degree2. cfm?data=yes&program=mdmba (Last accessed 1/16/2009.)

Several studies in recent years center around $1M as the contribution to revenue of each recruited physician. One such report appeared in Modern Healthcare, June 2, 2008; p30-31.

Hsiao WC, Stason WB. “Toward developing a relative value scale for medical and surgical services.” Health Care Financing Revue. 1979 Fall; 1(2):23-38.

Lauve, RM. “Primer on Healthcare Economics and Finance,” in A Survival Guide for Physician Executives, Tampa, Fla., American College of Physician Executives, 1994.

Richard Lauve MD, MBA, CPE, FACPE

Health care consultant based in Baton Rouge, La. rmlauve@bellsouth.net

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Decision Making

Does Your Organization Have DRIVE? By Niranjan Kissoon, MD, CPE, FACPE, Bradley J. Campbell, MHSA, and Nash Syed, MBA

In this article… Examine a process and framework for organizations to overcome pitfalls and achieve effective decision making.

operating models and decision-making frameworks are often ad hoc and informal. This leads to confusion, conflict, frustration and ultimately unsatisfactory decisions. Our belief is that the present climate more than ever before calls for bold decisions. These decisions to be successfully implemented rely on effective decision making.

Make it clear With each year, the challenges of delivering health care nationally are becoming more and more complex. There is a real sense that a looming crisis exists in health human resources, health financing and patient safety. These factors are raising questions of the overall sustainability of our system. While these questions are no different from those asked 10 years ago, the realities of their impact are much clearer and more immediate today. Addressing these health care challenges requires effective decisions that lead to successful actions and outcomes. But too often, health care organizations are hamstrung by ineffective decision-making processes that are neither clear nor well understood. The result is either a lack of a timely decision or a wrong decision. We believe that the solution is not in the decision itself but rather in the adoption of a solid decision-making model that can be understood by a broader group of stakeholders.

In an article titled “Who has the ‘D’,” Rogers and Blenko stress that good decision making depends on assigning clear and specific roles and clearly identifying who is accountable for both making, and then implementing, the decision.1 Building on the concepts described by Rogers and Blenko, we developed a model that we call DRIVE. DRIVE is a mnemonic that represents five key roles and tasks that are integral in decision making:

Simple model/complex process

This model is a simple way to ensure that key issues are addressed at the right time. The DRIVE framework can be converted to a simple, concise checklist that can be used to support any decision and any decision-making process. For small, locally based decisions, the leader can review this list and ensure that they have considered and assigned all roles. For larger decisions, such as those that are initiated at the senior leadership table, the senior team needs to discuss the various roles, and confirm and communicate responsibilities. In either situation, it is critical to clearly assign each of the DRIVE responsibilities in advance of the process being initiated.

We all have our own internal processes to determine what action we want to take and when. These processes are known to us (even if only at a subconscious level) but may not be known to anyone else. In many instances we do not translate our individual processes to the broader group or organizational level effectively. From our experience, decision-making processes by individuals and groups need to be formalized and articulated clearly within organizations. Having consulted to more than 100 health care organizations in Canada and internationally, we have found that 30

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1. Decide (making the decision) 2. Recommend (recommending options for a decision) 3. Input (being part of a consultation process) 4. Veto (challenging or obstructing the decision) 5. Execute (ultimately acting on implementing the decision)

The formal decision maker. He or she is ultimately accountable for the decision—good or bad—and must have the authority to resolve impasses in the decision-making process as well as during implementation.

The recommenders. Typically may consult with others, but they have responsibility to develop the ultimate proposal and recommendations. Someone is typically assigned responsibility to formulate an initial proposal or response to a problem or issue that is being examined.

Those with input typically will play a key role in enabling an implementation of a recommendation because they were part of the consultation process These individuals need to be consulted on the decision, and their advice is typically sought by a recommender, as well as by the ultimate decision maker, prior to the process being finalized.

Those with veto power must agree with the recommendation prior to it going forward for a formal decision. If these individuals do not agree, then the proposal is revamped until agreement can be reached.

Those chosen to execute. This stage provides clarity regarding timing, expected deliverables/outcomes and consequences for failure to act once a decision is made.

Without clear and appropriate decision-making processes, the ability to solve even the smallest issue can become overwhelming.

Decision breakdowns If it is as simple as we state, why are decision-making processes often viewed cynically and judged to be ineffective? Our explanation is that quite often we believe that we are all on the same page when this is not the case. As a result, attempts at realistic solutions are hampered by: • A lack of clarity regarding decision making roles and responsibilities • An underlying absence of formal accountability frameworks for support decisions • A lack of understanding of the consequences of not following through with a decision

Without clear and appropriate decision-making processes, the ability to solve even the smallest issue can become overwhelming for an organization, leading to a general lack of accountability and a failure to accomplish goals. Using the DRIVE model, it has been our experience that hospital leaders, either formal groups or individuals, are often very good at defining the recommend role, but they do not always provide the necessary clarity on any of the other roles. As a result, many individuals believe they have the right to provide input, to suggest or institute recommendations, to veto or make the decision, and to influence the execution of the decision.

It is therefore not surprising that processes breakdown as those responsible for recommending either don't engage, or more likely, over-engage stakeholders in the process. The result is either a recommendation that comes forward without adequate input and support, or recommendations that lack clarity and “teeth” and need to be revised repeatedly before acceptance. We have seen numerous examples of unclear and toothless recommendations that stem directly from not clarifying and effectively communicating the DRIVE roles, and their impact prior to decision making. Also, in the absence of clarity, some individuals may feel that they have veto power and therefore must agree in order for a decision to be

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endorsed and implemented. The same is true for situations where many feel that they should have input into every decision. Clearly failure to clarify roles has the potential to lead to unsatisfactory processes and outcomes.

Who's the decision maker? Finally, it is often difficult to know who is the decision maker. Sometimes individuals may assume they have the “D”, when they do not. In these situations, decisions can get made (or partially made) by people who have not engaged the right parties, do not have the appropriate authority or do not fully understand the issues on which they have made decisions. In other cases, no one wants to be the “D”, preferring instead to delegate decisions upward until they reach the senior leadership table. This upward delegation can lead to unnecessary delays, or worse, can sabotage the process so that a decision never gets made. If decisions are made at too high a level, these decisions may be suboptimal, because the content experts do not sit on senior management. Clarifying roles in advance, while essential, may also lead to conflict. This can be problematic as most of our organizational cultures do not deal well with open conflict in this area. However, lack of clarity is even more deleterious to organizations. It provides fertile ground for the naysayers and cynics in the organization to disrupt the process, sabotage the desired outcomes and may allow the wrong individuals to influence the ultimate decisions. Clarity upfront regarding the roles in a specific decision can help to manage this behavior.

Overcoming pitfalls Changing cultures, creating appropriate accountability frameworks and getting individuals used to a new way of operating is never easy. However, in our experience the DRIVE model provides an easy-to-use tool to assist people in acknowledging 32

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and accepting the crucial roles in the decision-making process. For senior teams, we encourage the CEO/COO to determine if the roles are clear whenever the team is asking for a proposal to resolve an issue. The team can quickly confirm: D Who should be making this decision? R Who should be asked to develop a proposal? I Who has to be consulted? V Who has a veto surrounding the recommendations? E Who should ultimately execute? (Although this may not be known until the recommendations come forward.) Here's how lack of clarity surrounding decision making can lead to dysfunction:

Case #1: A large teaching hospital had multiple committees. Some felt that they served an advisory function, while others felt that they had formal decision-making authority. When probed, it became clear that the level of authority was not well understood by all and that no actual decision had been made by some committees in more than two years. This was not due to a lack of interest, but rather because they were not asked to participate in decision-making processes. Virtually all decisions were made at the senior leadership table. Interestingly, senior leaders expressed frustration because they felt that decisions were actually being made by the CEO and a subset of senior leadership outside of the formal meeting. When decisions were brought to the senior table, there seemed to be confusion about whether it should be decided upon by the senior group. People also expressed that there was no clarity if a decision had been reached, and if so what was the deci-

sion and who is now charged with the responsibility to implement. In this case, the DRIVE model could have helped to clarify which decisions had to be made at the senior leadership table, versus those that should have been made by individuals or other groups. It would have also helped to define the “E” in these processes to reduce confusion for whether a decision had been reached as well as who was charged to execute or implement the decision.

Case #2: During the annual budget process at a large health authority, individual vice presidents were asked to find a percentage cost reduction to balance the budget. The vice president of clinical support services identified cuts in pharmacy and presented these as his contribution to the corporate plan. Part of the savings plan required nursing to pick up tasks previously performed by the pharmacy staff. Nursing leaders said that the pharmacy cuts could not be made if they led to increased pressure or costs in nursing. The plan was rejected, but the VP did not have to develop an alternate plan. In this case, it was not clear who had to agree with the plan before it could proceed. It was even less clear whether, in the absence of agreement from nursing, the VP had to develop an alternate proposal. In this case, there was a lack of clarity in the “I” and “V” roles. The proposal should have required input prior to coming forward and, in this case, nursing might have had a veto. Had this been done, the VP would have had to table an alternate recommendation.

Case #3: The corporate human resources department in a large multisite health care organization was faced with budget shortfalls and unilaterally decided to reduce the number of FTEs available to support recruitment of staff. This decision followed development of a Web-based job posting and

application process that HR believed would reduce the need for staff to support the process. The cuts were made. Afterwards, it was noted that much of the recruitment function had now shifted to the front-line manager (e.g. scheduling of interviews, reference checking and writing letters of offer of employment). The end result was decreased success in recruiting staff largely due to delays, increased frustration and an increased sense of disconnect and conflict between corporate services and front-line managers. In this case, the decision-making process contributed to the problem because a decision was made and implemented with limited input from the individuals that it would most affect. In the end, safe and effective care of our patients requires timely and appropriate decisions. The DRIVE model ensures that decision-making roles and responsibilities are clearly understood in advance of making a decision. As a result, the decision moves through a straightforward process, with appropriate input, review, acceptance that can lead to a successful implementation. The solution is a relatively simple approach that can be successfully used on decisions of any magnitude.

Niranjan Kissoon MD, CPE, FACPE

Professor in the department of pediatrics at the University of British Columbia. nkissoon@cw.bc.ca

Bradley J. Campbell MHSA

President of Corpus Sanchez International Consultancy, Inc., in Canada.

Nash Syed MBA

Senior vice president of Corpus Sanchez International Consultancy, Inc., in Canada.

Reference 1.

Rogers P and Blenko M. Who Has the D?: How Clear Decision Roles Enhance Organizational Performance, Harvard Business Review, Special Edition, January 2006.

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Op-Eds

PAY-for-PERFORMANCE Hit or Myth?

Why it Won't Work

In this article…

Examine why some think pay-for-performance programs need significant restructuring before they can make an impact and improve health care.

Consider how market forces and social conscience could be affecting the success of pay-for-performance programs.

By Alan P. Marco, MD, MMM, CPE, FACPE

By Kent Bottles, MD

The idea that placing financial incentives on the performance of physicians, hospitals, or other components of the health care system will lead to immediate and substantial improvement in performance—the care of patients—appeals to common sense. However, it is controversial whether or not this will actually happen. As P4P is currently constructed, it is largely a medical myth, much like other things that physicians do or recommend that are just “common sense” such as shaving the operative site before surgery (which can actually increase infection rates).1 Careful assessment of the evidence behind P4P in its current form will reveal that it is largely mythical and the link between pay and performance is not as clear as the public, physicians or payers would hope. The inherent problem with P4P is that most of the “quality measures” are not measures of quality, but of process.2 Even the Physician Quality Reporting Initiative (PQRI) measures, which the Centers for Medicare and Medicaid Services (CMS) call “quality measures,” are often process measures.3

“If one wishes to be a true scientist—an explorer not in search of what one desires to be true but rather in search of whatever truth there is—then one must be willing to accept, to engage, even to pursue further the most unwelcome and confounding data. One must be willing to make discoveries that shatter one’s most deeply held beliefs. Maybe it turns out that Earth is not the center of the universe.”

Continued on 36

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Rivka Galchen, Atmospheric Disturbances: A Novel1 The conventional wisdom is that pay-for-performance programs make a lot of sense. If physicians and hospitals are motivated by profit and if there is room to improve on the quality of medical care, then pay for performance will motivate providers to provide more value. There are four major reasons why pay-for-performance programs are gaining popularity: 1. The idea that people are more likely to do something if they get paid more to do it has a strong intuitive appeal.

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Hit or Myth? continued

Why it Won't Work continued

Some cost-containment programs masquerade as P4P.

Ariely writes that we live in two worlds with different sets of rules. In one world social norms prevail; in the other world market norms prevail.

For example, measure number 4, Screening for Future Fall Risk, is a process measure. Physicians are asked to report only that they “screened” the patients (a process), not whether they actually reduced falls (an outcome). Similarly, measures 5 through 8 refer to percentages of patients for whom certain medications are prescribed. This could be an outcome, but wouldn’t it be more effective if the physician actually got the patients to take their medications rather than just get credit for writing a prescription? While such an outcome measure has elements that are seemingly beyond the physician’s control, such as patient compliance, that just means that the standard should not be an arbitrarily high 95 percent or some such. Many others of these measures are for reporting that screening or communication has taken place, but are not actually measures of improved care. If one screens for a disease, but does nothing, credit would be given under PQRI without impacting patient outcomes. One review showed that of 17 studies examining the role of explicit financial incentives in improving the quality of health care, 13 were of process measures, not actual outcome measures. 4 However, there are some studies supporting the notion that improvement in process measures can improve outcomes also.5

What’s up in Hawaii? A classic version of P4P as a “myth-understood” concept is on the MedQIC Website (www.medqic.org). Following the links through the Hospital-SCIP-Stories buttons brings the viewer to the news story of how Hawaii Medical Center East improved its performance by achieving a 0 percent surgical infection rate. While this is laudable, close reading of the story as reported leads one to a different conclusion.6 The title is correct: “Hawaii Medical Center East Improves Quality Measures Through Participation in Surgical Care Improvement Project,” but the conclusion is wrong. According to the report, Hawaii Medical Center East reported a 0 percent infection rate for the third quarter of 2005. They also noted that they did not follow the SCIP

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2. There are large gaps in quality and delivery of evidencebased guideline recommended care. McGlynn, and others. famously found an overall adherence with recommended adult care of only 55 percent.2 3. There is a lack of a relationship between quality and costs at a regional level. 4. The devastating impact of increasing costs on American companies have hampered their ability to compete in a global marketplace. Conventional wisdom often masks “unwelcome and confounding data” because the subject has not been explored completely. Insights gained from neuroscience and behavioral economics question whether pay for performance will work; some believe that “extrinsic incentives” (financial compensation) can conflict with “intrinsic incentives” (the moral command to do one’s duty). These investigators believe extrinsic incentives can crowd out intrinsic incentives and result in failures to do one’s moral duty.3 O. Brafman and R. Brafman in Sway describe how the Swiss government identified a small town that seemed to be the ideal location for a necessary nuclear waste depository. When they presented the plan to the town hall meeting, about half the citizens said they would approve the plan and about half said not in my backyard. Believing they needed more public support, the government presented a plan to give all residents 5000 francs a year if the waste dump was built in their town. With financial compensation, the percentage of Swiss citizens who would approve the plan went from 50.8 percent to 24.6 percent, hardly the result that the officials anticipated. Raising the compensation above 5000 francs did not solve the problem. 4 Dan Ariely in Predictably Irrational writes about a day care center with a vexing problem of parents arriving late to

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Why it Won't Work continued

standards and undertook a broad restructuring of their perioperative process to improve their compliance with SCIP measures. But, with a “baseline in July 2005… of 0 percent,” what were they improving? Certainly not outcomes—they just improved their processes. Yet, this “improvement” is touted as a shining example of the success of SCIP. Some P4P programs, such as the Hospital Quality Initiative (HQI), can be successful. When used to create incentives for health systems, improvements in reported measures that more directly relate to patient outcomes, such as aspirin administration for acute myocardial infarction or “door-to-balloon” time in acute coronary syndrome, can be seen.7 However, in its current iteration, the HQI pays for reporting rather than improvement, although future linking outcomes to financial rewards is expected.8 A study assessing the validity of the Hospital Quality Incentive Demonstration (HQID) project showed that a hospital’s “performance” is highly dependent on process measures rather than outcome measures, with only 4 percent of the variability due to changes in the outcome of “survival.”9 Still, programs that rely on patient compliance, as many outpatient measures do, place the physician in the awkward position of bullying the recalcitrant patient or cherry-picking the patients who are most agreeable to the physician’s advice. In a recent survey, 82 percent of physicians responding were concerned about unintended consequences of P4P such as avoiding high-risk patients.10 Yet, P4P programs can be useful. While there are significant costs involved both in the collection of data and the increased financial incentives, the cost for each qualityadjusted life year is well within that considered to be a good investment.11 Other groups studying integrated systems have demonstrated savings to the payer.12 Still, at least in California, a leader in the P4P movement, payers have yet to save money.13 Incentive programs organized on the institutional (hospital or health system) level with sufficient resources and leadership commitment can improve quality of care.14,15 As an industry, health care must keep in mind that the patient is the ultimate payer both through the use of direct payments (co-pays and self-insurance), indirect payments (employer-sponsored health care plans in lieu of direct compensation), and governmental mediated financial transfers (e.g., taxes). P4P programs need to support patients’ free choice in providers. Without such choice, P4P programs may be as doomed as the cost-containment strategies of gatekeepers and capitation used by HMOs.16

pick up their children after school. The board of directors imposed a fine on parents who were late to pick up their children. The fine made the matter worse, and when the board removed the fine parents continued to be late. Social relationships are hard to reestablish once they have been redefined.5

Going in circles Ariely reports on studies that seem to find that paying research subjects does not always improve performance. In one such investigation the performance task was to move circles from one side of the computer screen to the other in a set amount of time. Subjects paid $5.00 moved 159 circles; subjects paid $0.50 moved 101 circles; but unpaid volunteers moved 168 circles. Ariely also reports that AARP requests to lawyers to lower their hourly rate of billing to $30.00 for poor seniors were unsuccessful, but many lawyers were happy to perform the work for free.5 In addition, Ariely describes research where one set of subjects read the sentence “it’s cold outside” and another group read “high paid salary” before performing a set of tasks. Those assigned the second phrase took more time to ask for help, were less willing to help others, avoided working in teams, spent more time alone, and sat farther away from other research subjects.5 In medicine this tension between financial compensation and moral obligations has been played out in the arenas of blood donation and organ transplantation. R. M. Titmuss’ The Gift Relationship compared blood donation in the United Kingdom (where the sale of blood is illegal) and the United States (where the sale of blood is legal). Titmuss found that the percentage of people who donated blood and the amount donated increased in the United Kingdom, when compared to the United States. He concluded that the “commercialization of blood represses the expression of altruism.”6 S. M. Rothman and D. J. Rothman make a similar case in arguing against establishing a market for organs for transplantation.3 What are these peer-reviewed studies telling us about the conventional wisdom that paying humans more will result in desired human behavior? Perhaps Richard H. Thaler and Cass R. Sunstein are on to something when they emphasize the importance of choice structures: how problems are presented to people.7 Ariely writes that we live in two worlds with different sets of rules. In one world social norms prevail; in the other world market norms prevail.5

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Why it Won't Work continued

Masquerade

On the brain

Some cost-containment programs masquerade as P4P. One example, according to the American Medical Association, is UnitedHealthcare’s (UHC) Premium Designation Program (PDP). This appears to the public as a rating system (two stars must be better than one), but is more accurately labeled a cost-containment program since there is no direct economic link to performance and achieving the higher two-star rating is based on an economic efficiency rating without appropriate risk adjustment.17 Medicare has proposed modifying its P4P plan into a system of withholds for less than stellar performance by including “an incentive payment that makes a portion of the base DRG payment contingent on performance.”18 If there were relevant outcome rather than process measures involved, this could be structured as a form of P4P rather than the current pay-for-reporting. Under this proposal, middle-performing hospitals have the most to lose, since the low-performing hospitals gain the most from potential improvement and high-performing hospitals already achieve the maximum incentive. The key issue will be whether or not such a plan is tied to true patient outcomes rather than process measures. If process measures continue to be used, will they be linked through real evidence to improved patient outcomes? That is unclear, and the proposed plan even states that “[t]here is even less evidence of the effect of P4P on patient outcomes,” which certainly casts doubt on the claim that “value-based purchasing” (the new moniker for P4P) will improve patient care, especially if it is based on lower base rates for care rather than new money. Without new money in the system, these P4P plans are actually pay-reduction plans as the “incentive” pool is structured so only a fraction of eligible hospitals receive the full incentive.

Brain imaging studies take this line of thinking one step farther. The pleasure center in the nucleus accumbens lights up when we are engaged in sex, drug use, gambling, and thinking about money. Is this the world where market norms prevail? The altruism center in the posterior superior temporal sulcus is responsible for how we perceive others, how we create community, and how we relate to fellow citizens. Does this center explain how we behave when social norms prevail? The latest neuroscience studies conclude that the pleasure center and the altruism center cannot both function at the same time; one of them has to be in control. 4 Ariely has the simplest and best explanation that summarizes my line of argument. We humans get in trouble when we mix social and market norms. Ariely writes that you will get into trouble if, after a delicious Thanksgiving dinner cooked by our mother-in-law, you try to show our appreciation by paying her $400.00.5 Should we at least try to understand what these studies are trying to tell us about the likelihood of success of pay-forperformance programs or should we just ignore the inconvenient scientific findings because conventional wisdoms tells us such programs make perfect sense?

What drives improvement? One final aspect of the P4P myth is that it is P4P programs rather than public reporting of data that makes a difference. Certainly, everyone wants to look good in publicly reported measures, regardless of their validity. Lindenauer reports that hospitals engaged in P4P programs in addition to public reporting achieved only modest additional gains over those merely reporting their data.19 Gains were inversely related to the baseline performance of the hospital. Similarly, a study of Massachusetts physician groups failed to show significant gains from P4P rather than the 38

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References 1.

Galchen R. Atmospheric Disturbances: A Novel. New York, Farrar, Strauss and Giroux, 2008.

McGlynn EA. “The Quality of Health Care Delivered to Adults in the United States.” New England Journal of Medicine 348; 2635, June 26, 2003.

Rothman SM and Rothman DJ. “The Hidden Cost of Organ Sale.” American Journal of Transplantation 2006; 6: 1524-1528.

Brafman O and Brafman R. Sway. New York, Doubleday, 2008.

Ariely D. Predictably Irrational. New York, Harper, 2008

Titmuss RM. The Gift Relationship. New York, Vintage Books, 1971.

Thaler RH and Sunstein CR. Nudge. New Haven, Yale University Press, 2008.

Kent Bottles MD

President of the Institute for Clinical Systems Improvement in Bloomington, Minnesota. Kent.Bottles@icsi.org

Hit or Myth? continued general improvement in care in during that time period in Massachusetts.20 In a study of the National Health Service in Britain, it was observed that competition actually worsened outcomes in emergency admissions for acute myocardial infarction.21 The authors postulate that since wait times were measured and reported but mortality rates were not, resources were redirected into areas that improve reported scores rather than the outcome of improved survival. Thus, P4P programs need to ensure that the Hawthorne Effect is not the primary effect induced and that unintended consequences do not result from implementation of these programs. The final chapter on P4P has yet to be written. Like many myths, there is some basis in reality. Under certain circumstances, P4P as it is currently constructed could improve outcomes. While P4P is here to stay, there are still significant structural and procedural issues to resolve before P4P can be described as a hit rather than a myth.

References 1.

Celik SE, Kara A. Does shaving the incision site increase the infection rate after spinal surgery? Spine July 1, 2007, 3(45): 31(3): 1575-7.

Sage WM, Kalyan DN. Horses or Unicorns: Can Paying for Performance Make Quality Competition Routine? Journal of Health Politics, Policy and Law, June 2006:531-60.

http://www.cms.hhs.gov/pqri/ accessed February 24, 2008

Peterson LA, LeChauncy DW, Urech T, and others. Does Pay-forPerformance Improve the Quality of Health Care? Ann Intern Med. Aug. 15, 2006;145(4):265-272.

Millett C, Gray J, Saxena S, et al. Impact of a pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes. CMAJ June 5, 2007;176(12):1705-10.

Hawaii Medical Center East Improve Quality Measures Through Participation in Surgical Care Improvement Project http://medqic.org/ dcs/ContentServer?cid=1205442145582&pagename=Medqic%2FMQNews %2FNewsFeatureTemplate&c=MQNews accessed January 23, 2009.

http://www.premierinc.com/quality-safety/tools-services/p4p/hqi/ resources/hqi-whitepaper-year2.pdf accessed January 23, 2009.

Smoldt RK and Cortese DA. Pay-for-Performance or Pay for Value? Mayo Clin Proc.. February 2007;82(2):210-3.

O'Brien SM, and othersl. “Exploring the behavior of hospital composite performance measures: an example from coronary artery bypass surgery.” Circulation, Dec. 18 2007, 116(25) 2969-75.

11. Nahra TA, Reiter KL, Hirth RA, et al. Cost-Effectiveness of Hospital Pay-for-Performance Incentives. Medical Care Research and Review, Vol. (Supplement to February 2006;63(1): 49S-72S. 12. Curtin K, Beckman H, Pankow G, et al. Return on Investment in Pay for Performance: A Diabetes Case Study. Journal of Healthcare Management Nov/Dec 2006; 51(6) p 365-76. 13. Terry K. Is P4P Getting Tougher? Medical Economics. July 20, 2007; 84(14): 36-8. 14. Sautter KM, Bokhour BG, White B, et al. The Early Experience of a Hospital-Based Pay-for-Performance Program. Journal of Healthcare Management March/April 2007; 52(2): 95-107. 15. Grossbart SR. What’s the Return? Assessing the Effect of “Pay-forPerformance” Initiatives on the Quality of Care Delivery. Medical Care Research and Review, Vol. 63 No. 1, (Supplement to February 2006) 29S48S. 16. Safavi K. Patient-Centered Pay for Performance: Are We Missing the Target? Journal of Healthcare Management July/August 2006 ;51(4): 215-8. 17. UnitedHealthcare's "Premium Designation" program. Available at http://www.ama-assn.org/ama1/pub/upload/mm/368/uhc_pd_chart.pdf accessed Jan. 23, 2009. 18. Plan to Implement a Medicare Hospital Value-Based Purchasing Program. http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/ HospitalVBPPlanRTCFINALSUBMITTED2007.pdf accessed Jan. 23, 2009. 19. Lindenauer, PK, Remus D, Roman S, Rothberg MB, Benjamin EM, Ma A, Bratzler DW. Public Reporting and Pay for Performance in Hospital Quality Improvement. N Engl J Med Feb. 1, 2007;356:(5)486-96. 20. Pearson, SD, Schneider EC, Kleinman KP, Coltin KL, Singer JA. The Impact Of Pay-For-Performance On Health Care Quality In Massachusetts, 2001-2003. Health Affairs, Jul/Aug2008, p1167-76. 21. Propper C, Burgess S, Gossage D. Competition and Quality: Evidence from the NHS Internal Market 1991–9. Economic Journal, Jan. 2008, 118(525): p138-70.

Alan P. Marco MD, MMM, CPE, FACPE

is professor and chair of the department of anesthesiology at the University of Toledo in Toledo, Ohio. alan.marco@utoledo.edu

10. Casalino LP, Alexander CG, Jin L, Konetzka RT. General Internists' Views On Pay-For-Performance And Public Reporting Of Quality Scores: A National Survey. Health Affairs March-April 2002; 26(2):492-9.

ACPE.ORG

Management Education

Medical Leaders Wanted— Business Degree Desirable By Arthur Lazarus, MD, MBA, CPE, FACPE

In this article… Although many will disagree, what physicians learn in business school is truly the key to success when it comes to running a health care organization.

The business of health care is unique. Medical delivery does not conform to usual market dynamics, and medical services and products are not household commodities. Because medical practice is so special, hospitals and health systems rarely import executives from other business sectors. Contrast medical leadership with leadership in the auto industry, for example, where two “outsiders” were called on to rescue Detroit’s struggling automakers. Ford Motor Company named former Boeing executive Alan Mulally as its president and CEO in September 2006. Robert Nardelli, ex-chief of Home Depot, assumed the top post at Chrysler in August 2007. Individuals with strong leadership and management skills can transcend many types of industries, but shouldn’t executives have specific training in medicine when it comes to leading health systems—training beyond on-the-job experience? More than 20 years ago, health care experts identified several core competencies required to manage the “medicalindustrial complex.”1 Key areas included marketing, finance, accounting, economics, strategic planning, operations management and the decision sciences. A degree in medicine was not considered a prerequisite.

Pharmaceutical leaders In reality, in the pharmaceutical industry, leaders without formal education in medicine or science appear to be the rule: sales and finance have spawned the majority of senior executives and pharmaceutical CEOs. Andrew Witty, CEO of GlaxoSmithKline, is an economics graduate from Nottingham University. Jeffrey Kindler, the CEO of Pfizer, is a Harvard-trained lawyer. Prior to joining 40

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Pfizer in 2002 as senior vice president and general counsel, Kindler was a senior executive at McDonald’s. And Pfizer’s CFO, Frank D’Amelio, began his career at Bell Labs. Before joining Pfizer, he was chief administrative officer of Alcatel-Lucent, the telecommunications equipment and service company based in Paris. Witty was selected for his global experience and perceived ability to grow the business in emerging markets. Kindler was admired for his wide-ranging business and management skills. D’Amelio was chosen for his ability to control costs and right-size operations. The long-standing practice of appointing highly talented people with diverse backgrounds to top pharmaceutical posts should send a signal to the rest of the health care industry. It suggests that experience in global companies undergoing rapid consolidation and complex changes may count more than having a medical degree or experience in U.S. health care organizations. Making the changes necessary to reform the U.S. health care system requires a rigorous and disciplined focus on business and strategy. I was never taught how to do that in medical school. Business school, on the other hand, provided such a learning opportunity.

Business school Although my medical education was invaluable, and it clearly set me apart from non-medical executives, business school—not medical school—helped prepare me for a career in medical management. My career has spanned academic medical centers and managed care and pharmaceutical companies, including roles as hospital chief medical officer and health maintenance organization vice president. It seems only natural that medical schools, especially those that are affiliated with large university systems and schools of business, should provide students the necessary business acumen to be successful, whether in private practice or as a physician executive.

It seems only natural that medical schools, especially those that are affiliated with large university systems and schools of business, should provide students the necessary business acumen to be successful.

ACPE.ORG

But medical educators have fallen short of this goal, and medical students who show an interest in the business side of medicine are sometimes branded as “traitors.”2 The idea that physicians should be trained in business is anathema to many in the medical profession. Some say that doctors cannot possibly have both business and patient interests in mind at once. Others may say medical school curricula are already overloaded with science courses, leaving no room for business courses. Even an expert in management has realized that: “MBA programs by their nature attract many of the wrong people—too impatient and analytical, with little experience in management itself. These may be fine traits for students, but they can be tragically ill-suited for managers.”3 Still, there is a growing awareness of the lack of business-trained physicians in leading positions in hospitals and academic medical centers. Increasingly, the phrase “business degree desirable” is appended to classified advertising geared toward physician executives. There is also a growing recognition of the importance of the need for physician-led transformation of the U.S. health care system. Physicians with business training are primed to lead this transformation, given their enhanced leadership and management skills. In fact, more than 50 U.S. medical schools offer combined MD-MBA programs (refer to http://www.md-mba.org for a complete list of schools). Students enrolled in these programs need the support of their medical school faculty more than ever, and skeptical faculty members need to realize that dual degree programs attempt to complement medical education with management education rather than the converse. It will be important to track the careers of graduates of MD-MBA programs and assess their impact on the evolving health care system.

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• Is medical school the optimal time to obtain an MBA degree? • Will there be opportunities for newly minted MD-MBA graduates to use their knowledge and demonstrate their value early in their careers? • Will the MD-MBA replace the esteemed MD-PhD as the dual degree of choice? The students enrolled in MD-MBA programs are unique in terms of their career aspirations and reasons for selecting business training early in their careers. As future physician executives, they deserve our attention. As future medical leaders, they are certainly worthy of nurturing and guidance.

References 1.

Hillman AL, Nash DB, Kissick WL, Martin SP. Managing the medicalindustrial complex. N Engl J Med Aug. 21, 1986;315:(8):511-513.

Sherrill WW. The traitor complex. The Physician Executive Jan-Feb 2005;31(1):48-9.

Mintzberg H. The MBA menace. Fast Company, Issue 83 June 2004, page 31 (Available at http://www.fastcompany.com/ magazine/83/mbamenace.html.)

Arthur Lazarus MD, MBA, CPE, FACPE

Executive-in-residence at Temple University Fox School of Business and Management and senior director of clinical research at AstraZeneca Pharmaceuticals in Wilmington, Delaware. arthur.lazarus@astrazeneca.com.

His opinions are his own and not necessarily those of AstraZeneca.

CPE?

Get Noticed!

What people are saying about becoming a

Certified Physician Executive

Participants

Recruiter

“I had been putting off getting the CPE, but when I began a job search, three out of five recruiters asked me if I was a CPE — so I knew it was time to do it.”

“There are several reasons that a recruiter would like to see the CPE credential on a resume. First, the CPE says that you have further prepared yourself to compete in the health care management arena.

M. Joseph Grennan Jr., MD, CPE Senior Vice President and Chief Medical Officer Humility of Mary Health Partners Youngstown, Ohio

“The CPE program better prepared me to deal with challenging communication issues and trained me how to give a concise persuasive delivery of my own accomplishments which has advanced my career”

Jay Haynes, MD, MSMM, CPE Chief Medical Officer Senior Vice President JPS Health Network John Peter Smith Hospital Fort Worth, Texas

Second, in a competitive market it is a differentiator between you and other qualified candidates. It gives you a decided edge. Third, it shows your commitment to the profession of being a physician executive. By taking on this extra effort, a recruiter sees that you are serious about wanting to advance and will to do the things necessary to move forward in your career. ACPE designation shows that you are truly committed. ”

J. Larry Tyler President, Tyler & Company Executive Search Consultants

Upcoming Tutorials September 13–17, 2009 Dallas, Texas February 2010 Tampa, Florida • Dates TBD

Learn more about how you can achieve Board Certification in Medical Management Call for a personal evaluation of your eligibility: Tina Ramsey, 800-562-8088 or TRamsey@acpe.org ACPE.ORG

Recruiting

The Search for Effective Physician Leaders: New Strategies for New Challenges By Kurt Scott

In this article… Take a step-by-step look at how to recruit, interview and hire physician leaders.

As health care organizations become increasingly complex and competitive, the search for effective physician leaders becomes a sink-or-swim issue. Physician executives today must build new programs, fix ailing ones, secure referral and payer networks, manage professional staff, recruit new talent, understand and plan for budgetary and regulatory challenges, and much more. The hard truth is physician leaders of the past—often senior and very well-respected members of the medical staff promoted into the job—may not have what it takes to lead today. Here are some suggestions to help you gather the right team, build a solid plan, set expectations, avoid some common pitfalls, and find the best clinical executive for your organization.

Establish your executive search committee Recruiting physician leaders is one of the most important steps in building or changing the culture of your organization. Go into the process deliberately, with a clear idea of the change you need to make or the standard you need to uphold. Create a core executive search committee that participates in all physician leadership searches, regardless of program or specialty. Do not create a different committee for each search; you will lose consistency, vision, and the chance to build a team of “super interviewers.” Do plan to add ad hoc members to the core team based on the position you are filling. The committee should be heavily weighted toward physicians. Interview them and select those who will critically assess candidates and are positive and supportive of the position and your effort to fill it. Most importantly, they must be committed to participating in first-round interviews. 44

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Set clear expectations for the committee’s role Committee members must understand that their role is to evaluate, screen, and recommend candidates, not pick the winner. The final decision must be that of the hiring leader—always. The committee should present two or three candidates they can support. They may rank them, but given the competitive nature of recruiting, they must be comfortable and supportive of all recommended candidates.

Fine-tune and agree upon selection criteria Discuss the qualities and experience the perfect candidate would possess. Discuss scenarios that are questionable or raise “yellow flags.” Come to consensus on criteria that are required and that are “nice to have.” This list helps you evaluate candidates consistently, and it ensures your compliance with equal employment opportunity and affirmative action laws. Categorize your list and split it up among committee members, making each member consistently responsible for asking questions and assessing candidates in a particular area. This makes the interview process fresh and interesting for both sides. Of course every interviewer may ask general questions and follow interesting threads of conversation. Provide a quick refresher on legal interviewing. Contact your human resources department for assistance. This is important to the success of your process and the protection of your institution.

Create a “resource compendium” Compile a resource compendium that includes such things as: • Organizational chart(s) • List of personnel (doctors, mid-levels, nurses, administration, and support staff)

Recruiting physician leaders is one of the most important steps in building or changing the culture of your organization. Go into the process deliberately, with a clear idea of the change you need to make or the standard you need to uphold.

• Copies of staff CVs

• Opportunities for growth

• Full outline of services provided, programs and special procedures offered, etc.

• Challenges or roadblocks

• Special equipment • Hours of operation

• Research activities • Educational opportunities • Department turnover and recruitment activities

• Budget reports • Revenue reports • Square footage and layout

Start this process early; it will take time.

Screen in before you screen out Cast your net as widely as possible. You want a large candidate pool going into your recruitment funnel. Yes, it’s time-consuming, but it gives you essential context in which to compare candidates. The screening process gets tougher as candidates work their way through it.

ACPE.ORG

Screening great candidates is relatively easy. So is screening out weak candidates. Your challenge will be to train and motivate committee members to screen candidates who seem to fall in the middle. The screening process should include:

Self-selection—Make sure the advertising, Web postings, outreach postings, email and direct mail campaigns created for the position contain enough information Physician executives appreciate straightforward, relevant information about compensation, incentives, resources, teaching and research expectations, administrative/ clinical mix, and leadership scope. They will need basic community information as well. Your organization’s Web site should give candidates enough information to opt into your recruiting process. The page should branch off your “Careers at...” or “Opportunities for Physicians” section. This page should focus on the position and introduce the candidate to the mission and reputation of the organization and the department, potential colleagues, and related efforts throughout the institution. This is a great place to expand on the benefits of the position and to highlight community attractions and resources. Include the URL in all advertising.

First phone interview—Use the first call as a high-level screening tool. Cover the items in your criteria lists thoroughly so you know any candidate who makes it to a second interview is qualified. Be sure to gather as much information as possible about the candidate’s experience, personal and professional motivations, and other job prospects or prospecting in the works. It’s often easier for professional recruiters to ask some of these questions and speak candidly with the physician about the fit of the job. Let them be your super screeners. 46

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The recruiter can outline the compensation package, but only the hiring manager should negotiate with a candidate.

Second phone interview—Next, a member of the committee should conduct a phone interview with the candidate, using the criteria list to guide the interview. He or she should use openended questions to create a dialog that lets the physician’s character and personality come through. Saying, “Give me an example of a time you...,” or “Tell me how you handled a situation like...” are great ways to move candidates from generalities to specific, meaningful answers.

Present candidate to committee— The same committee member should present the candidate to the full committee. Building on the profile started by the recruiter in the first phone interview, the committee member should review the candidate’s relevant experience, interest in the position, fit with the position and the organization, and any potential red flags. Next is recommending whether the candidate should be invited to the first round of on-site interviews.

On-site interviews—Scheduling may be the hardest and most crucial aspect of on-site interviews. Committee members must be willing to keep their schedules flexible. Remember, desirable candidates are not just desirable to you. There will be competition from other organizations. It’s important to build on the momentum of the initial interviews. All members of the committee should complete a candidate evaluation form the day of the interview.

Spouse recruitment—Paying careful, deliberate attention to the needs and preferences of a candidate’s spouse is tremendously important because the spouse contributes at least 50 percent to the overall decision.

Recruit a group of committee members’ spouses. The group should include a variety of ages, gender, interests, and work situations. You do not need to ask the entire group to meet with each interviewee’s spouse. Pick and choose based on similar interests. Spouse recruiters should be willing to do some legwork for the family prior to the visit. They may be asked to check out special schools, for example, or to help target areas to include in a tour with a realtor. This team should plan on having lunch with the spouse on interview day, joining the community tour with a realtor, and assisting with introductions at any evening functions. In the best case, a member of this team will strike up a friendship with the spouse and be available to answer questions during recruitment and help out during relocation if applicable.

On-site interviews that wow them The competition for great physician leaders is intense. You have to develop an on-site interview process that far exceeds candidates’ expectations. Your goal is to have each candidate leave your organization feeling like he or she is the most important candidate. Customize the interview to the needs and preferences of each candidate. For example, a candidate who expresses an interest in research should spend a good amount of time with leaders and colleagues in that area. Schedule 45 minutes for each interview, with a 15-minute buffer to allow the candidate and host to get to the next interview on time. Make sure water and bathroom facilities are easily accessible. Always assign a host to shepherd the candidate to interviews and appointments. He or she should be conscientious about maintaining the flow of the day, keeping interviews within time limits, answering questions as they come up, and developing contingency plans if things get off track.

Physician In Management 2009 Live Seminar • April 24–28, 2009 • Hyatt Regency Chicago

Opening the Doors of Possibility For over 30 years the Physician in Management Seminar (PIM) has opened new doors of possibility and perspective for physicians choosing to pursue management and leadership training and education. The PIM course teaches the key principles and concepts necessary to understand the disciplines required in managing and leading at all levels and organizations within health care. Choose the full course or take individual modules • Marketing and Strategic Planning (full-day) Eric Berkowitz, PhD

• Increasing your Influence (full-day) Charles E. Dwyer, PhD

• Valuable Communication Skills (half-day) Timothy Keogh, PhD

• Management Skills (half-day) Michael B. Guthrie MD, MBA, FACPE • Finance in Health Care Organizations (full-day) Hugh W. Long, MBA, PhD, JD

• Powerful Negotiation Skills (full-day) Linda Babcock, PhD

Earn credit toward your Master of Medical Management or Online MBA degree—Each PIM module is approved for credit in ACPE’s graduate degree programs. For more info on the degree program go to ACPE.org/Degrees. Order the Physician in Management program at ACPE.org or call ACPE at

800-562-8088

813-287-2000 (outside US) Can’t make it to Chicago? Complete this course from the comfort of your home on InterAct Distance Education www.acpe.org/interact

ACPE.ORG

The host should be alert to potential red flags in the candidate’s behavior or comments, and alert the hiring manager as soon as possible. This will allow the hiring manager to investigate or address an issue immediately. The host should also be a warm, subtle advocate for the candidate. A savvy realtor is another important factor. Recruit a realtor who will act and be perceived as an extension of your organization. Make sure the realtor contacts the candidate and spouse before the on-site interview to develop a good understanding of their needs and priorities. The realtor should lead a valuable, time-wise community tour that leaves the candidate and spouse feeling that the community could work for them.

Round one The first round of on-site interviews should be conducted by committee members plus any ad hoc members closely connected to the search based on position, specialty, or candidate’s area of interest. Remember that ad hoc members should have been recruited to the committee at the outset, and should be very familiar with the position and criteria you have established. For example, if you are recruiting a chair of neurosurgery, you may include the department head of neuroradiology, the vice president of operations for neurosciences, and the department head of neurology. The committee should discuss and evaluate candidates interviewed each week. Remember, the job of the committee is to recommend candidates with the highest likelihood of success.

Round two Second-round interviews should be conducted by committee members plus the organization’s executive leadership team, including the CEO, CMO, and COO. Leaders from other departments can be included based on the position and the candidate. 48

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Once again members of the spouse recruitment committee should be included. As committee members spend time with the spouse they will uncover any potential family issues that might influence the decision or fit for the position. For example, in one recent situation a candidate had a son in a challenging magnet high school, despite the son’s mild learning disability and need for slight accommodation. A member of the spouse recruitment committee set up appointments for the parents with administrators at two schools in the new town, which gave the parents confidence their son could find a positive fit at one of the schools. After all second round interviews are complete, the committee should do a final review of all candidates, recommending the top two or three candidates they can fully support. These candidates’ profiles and interview summaries should be presented to the hiring manager.

The final step The hiring leader should ask the top candidates to prepare a department vision statement. These will be up to 30-pages long, including major goals for the next three years, major programs to be developed or enhanced, staffing levels, revenue projections, required resources, potential obstacles or challenges, and major equipment to be purchased. This is a tall order, but it is feasible to require this of top candidates. Vision statements provide great insight into candidates’ experience and perspective. Sometimes your second choice candidate emerges as the top choice through the process. The hiring leader will base his or her decision on the profiles, the interviews, and these statements.

Offer and the close Closing the deal actually starts during the offer stage. The offer

should be made verbally by the hiring manager. Tell the candidate that no paperwork will be sent out until oral agreement is reached. This may sound strict, but it is very important. It is not at all uncommon for a candidate to take a client’s contract or letter of offer and “shop it around” to other potential openings. It’s also true that candidates want what they don’t have, so the offer letter is a powerful closing tool. It is more effective to get the candidate to decide if this is truly the position he or she wants, and under what circumstances. Coach the candidate to put together his or her entire list of wants and desires. It is in the candidate’s best interest to compile and submit the whole list at one time and not ask for something new in every call, which looks like they are trying to “hold up” your organization. Once the negotiation process is completed and the candidate accepts the terms, you can send the appropriate paperwork by registered mail, requesting a return receipt. The agreement should expire or be extended after seven days, as you choose. Now, take a deep breath. It is not often a candidate goes through this process and then turns down the job at the 11th hour.

Kurt Scott Director of physician search and consulting for VISTA Staffing Solutions based in Wilkes-Barre, Pa. kurt.scott@Vistastaff.com

ACPE’s Annual Meeting

Inspiring physician leaders — Improving health

ACPE.org/annual

American College of Physician Executives

ACPE’s Annual Meeting

Tap into the enthusiasm, optimism and curiosity you had when you entered your clinical training and do what you can to heal health care. Join us for our 2009 Annual Meeting — you’ll meet people like yourself who share the common bond of being physicians who can make a difference.

Don’t miss these once-a-year events: Friday, April 24 • 4:45pm – 5:45pm

Keynote Session Reaching Your Summit — Peter Athans Gear up for a thrilling presentation by Peter Athans, known in climbing circles as “Mr. Everest” and an avid student of philosophy, poetry and prose. His riveting experiences will compel you to join him on an expedition of your own — affirming his belief that everyone has his or her own Everest.

Friday, April 24 • 11:30am – 1:00pm

Meeting of the Members Come elect your Board members and hear about the business of the College.

Saturday, April 25 • 6:00pm – 9:00pm

ACPE.org/annual

An Evening to Celebrate: ACPE/CCMM Dinner & Induction Ceremony Recognize the College’s new Fellows and Certified Physician Executives while enjoying a fabulous dinner and entertainment. Induction Ceremony is $125 per person (ACPE members and nonmembers). Admission is included in the Vanguard registration.

ACPE’s Annual Meeting

Saturday, April 25 • 8:00am-4:30pm

Leadership Summit – Reaching Your Goals, Recapturing Your Passion 7 CME credits • $600 members/$675 non-members

What led you to where you are today as a physician? Are you frustrated by the mountains you see blocking your path to real satisfaction? Do you wish you could summon the enthusiasm you had when you first became a doctor?

Let ACPE guide you on the climb toward your own summit. Behind the scenes with “Mr. Everest”

Voices from the Top

Peter Athans

A fast-paced dialogue with key leaders who’ve reached a career summit of their own. They’ll share their view from the top and the significant experiences they’ve encountered along the way.

An unforgettable opportunity, available only to Summit participants, to chat with Peter Athans. He will address questions on everything from mountaineering to professional exploration and philosophy.

Influence in the Boardroom Influence Yourself — Base Camp

Michael Guthrie, MD, MBA

Barbara Linney, MA

The path from the bedside to the boardroom is rocky but once you make it there, your sphere of influence can expand greatly. Learn how to successfully navigate your way to the boardroom and start making a difference once you’re there.

Climbers prepare for the first phase of their ascent at Base Camp, an emotionally charged experience filled with excitement, fear, humility and competition. In this session you will take stock of what is happening in your work and life and decide what challenge you would like to reach for next. We’ll identify the risks and determine the support you’ll need for the trip.

Influence Your System — Bedside & Beyond Craig Clapper, PE, CQM

Alfredo Vigil, MD Secretary of the New Mexico Department of Health Hear how Dr. Vigil’s 30 years of extensive clinical and management experience led him to a surprising turn in his career: leading health policy at a state level. Like the unpredictability of the mountain, sometimes opportunities present themselves when you least expect them and a decision must be made quickly if you hope to improve health on a larger scale.

Re-Entry After examining several professional summits for physician leaders, determine what is next for you and prepare for your own journey.

ACPE.org/annual

No matter what your ultimate goal is, you will need to know the principles of high reliability and teamwork. In this session, you will learn how to prevent, detect and correct errors that threaten your patients’ safety and demoralize caregivers. Mastering this science will help you inspire your care team to higher performance and make the difference you desire at the bedside and beyond.

Influence Policy

ACPE’s Annual Meeting

Make the most of your time away — combine the Annual Meeting Events with an ACPE educational course Annual Meeting Events

Friday April 24

Saturday April 25

Sunday April 26

Monday April 27

Tuesday April 28

Prices Members/Nons

Meeting of the Members

11:30am – 1:00pm

Open to all attendees

Keynote Session with Peter Athans

4:45pm –5:45pm

Open to all attendees

Leadership Summit: Reaching Your Goals, Recapturing Your Passion

8:00am – 4:30pm

$600/$675

An Evening to Celebrate: ACPE/ CCMM Dinner & Induction Ceremony

6:00pm – 9:00pm

$125

Courses Lessons in Leadership: Do You Have What it Takes?

8:00am – 4:30pm

$350/$425

Best Practices in Managing a Hospital Medicine Program

8:00am – 4:30pm

$595/$645

Crucial Conversations® in Medical Management

8:00am – 4:30pm

Leadership & Governance for Group Practice Board Members

8:00am – 4:30pm

8:00am – 12:00pm

$870/$945

On the Frontline! Leadership & Management Skills for Dept Heads

8:00am – 4:30pm

8:00am – 12:00pm

$870/$945

Managing Physician Performance

8:00am – 4:30pm

7:00am – 12:30pm

8:00am – 4:30pm

Finance

Marketing

Negotiation

Physician in Management Solve This! Breakthrough Thinking for Physician Executives Physicians & Hospitals: Proven Techniques to Optimize the Relationship

8:00am – 4:30pm

$800/$875

$1,525/$1,675

7:00am – 12:30pm Communication 8:00am – 11:30am Management Skills 1:00pm – 4:30pm

Influence

7:00am – 12:30pm

8:00am – 4:30pm

7:00am – 12:30pm

$800/$875

8:00am – 4:30pm

$395/$470

The Vanguard Program

ACPE.org/annual

(Registration includes all Annual Meeting Events)

ACPE's Keystone: The Blueprint for High Performance MetaLeadership: Removing Barriers and Building Bridges

$1,475/$1,550

8:00am – 4:30pm

$925/$1,075

8:00am – 4:30pm

7:00am – 12:30pm

8:00am – 4:30pm

7:00am – 12:30pm

$1,525/$1,675

8:00am – 4:30pm

7:00am – 12:30pm

$800/$875

Friday • April 24

Lessons in Leadership: Do You Have What It Takes? $350 ACPE members / $425 non-members • 7 CME credits

Kevin O’Connor, MA, CSP William Martin, PsyD, MPH, CHES Barbara Linney, MA Timothy Keogh, PhD Eric Berkowitz, PhD This jam-packed, one-day course is the perfect introduction for physicians entering, or thinking about entering, health care leadership. It’s also a great course for experienced physician leaders that goes beyond the refresher and equips the senior leader with an updated toolkit to take back home. Expert faculty from across the country will offer insights on

• • • • •

Creative problem solving Building successful teams Achieving organizational objectives Marketing your organization

Lessons in Leadership: Do You Have What It Takes? Ends with a powerful keynote address by Peter Athans, a famous Mount Everest climber who saved the lives of other mountaineers on the deadliest day in the history of summiting Mount Everest. Athans talks about the mistakes made by the climbers.

ACPE’s Annual Meeting

NEW COURSE!

“What was strange was that these groups disregarded some of the protocol we’d all agreed upon during our years of figuring out how to climb and guide Everest. They abandoned all the rules . . . people got into a situation where strong decisions had to be made, and no one was there to make them.” Athans’ insights on leadership and teamwork will leave you exhilarated and ready to tackle new challenges when you return to your health care organization after this inspiring one-day course. Skills, connection, solid approaches, interactive adult learning, experienced faculty who know how to teach, and an inspirational speaker are all part of this memorable ACPE day.

Achieving your career goals.

s New Courses t NEW COURSE!

Friday • April 24

Best Practices in Managing a Hospital Medicine Program $595 ACPE members / $645 non-members • 7 CME credits

John R. Nelson, MD Martin Buser Burke Kealey, MD Joseph Li, MD Winthrop F. Whitcomb, MD

Hospital medicine is the fastest-growing medical specialty in the U.S., with over 20,000 hospitalists today and perhaps 30,000 by the end of the decade. This course, offered in collaboration with the Society of Hospital Medicine, focuses on how to improve the management and operation of an existing hospital medicine program or how to start a new one.

ACPE.org/annual

Expert faculty who are experienced hospitalist program leaders and consultants will deliver practical tools such as templates, checklists, references, and benchmarks you will be able to take home and use immediately.

ACPE’s Annual Meeting

s New Format t

Sunday-Monday • April 26-27

Vanguard Program $925 ACPE members / $1,075 non-members • 12 CME credits

This is one Vanguard you won’t want to miss! The Vanguard Program is the “Must Attend” meeting for experienced Physician Executives. Seasoned physician executives who are Fellows, Certified Physician Executives or who hold advanced degrees in management are welcome. This year’s Vanguard format is new and spans four days. Register for Vanguard and take your pick of sessions and activities. Come in Friday for the Meeting of the Members and the Keynote kickoff session. On Saturday enjoy ACPE’s newest course, The Leadership Summit. Saturday evening your registration includes the ACPE/CCMM Induction Ceremony and Dinner. Sunday and Monday Vanguard sessions feature superb faculty and relevant topics in personal and professional growth.

Friday, April 24 • 11:30am – 1:00pm

Meeting of the Members (non-members welcome to attend)

Friday, April 24 • 4:45pm – 5:45pm

Keynote Session: Reaching Your Summit — Peter Athans Saturday, April 25 • 8:00am-4:30pm

Leadership Summit – Reaching Your Goals, Recapturing Your Passion

Sunday, April 26 • 1:00pm–4:30pm An Afternoon at the Art Institute of Chicago Escape for an inspiring afternoon at one of Chicago’s cultural icons. A recent Harvard Medical School study revealed that looking at fine art makes better doctors. You will enjoy a private lecture “The Discerning Eye,” created specifically for health care professionals. Learn what triggers your visual interest and how you translate this information when interacting with others. Train your eye to wade through our world’s increasing visual stimuli and extract the critical observations needed to make informed decisions. Following the presentation you will be free to tour the Institute’s galleries on your own.

Saturday, April 25 • 6:00pm – 9:00pm

An Evening to Celebrate: ACPE/CCMM Dinner & Induction Ceremony

Monday, April 27 • 8:00am–11:30am

Sunday, April 26 • 8:00am–11:30am

Executives

Tribal Leadership:

Building a Culture of Excellence in Health Care

ACPE.org/annual

Dave Logan, PhD Halee Fischer-Wright, MD, MMM Culture within health care is the most important factor that affects quality, satisfaction, and patient care. This highly interactive and entertaining session focuses on how to identify the culture present within your organization, and how to improve it using the techniques that are derived from the latest research. The result of this session is an understanding of how culture affects organizations, the leverage points to improve culture, and how to create high performance teams.

Debunking the Myths of Integrated Health System Economics: The Key Role of Physician Daniel Zismer, PhD Hear Dr. Zismer present results from his recent research on the critical role of physician executives in integrated health systems. Find out what drives revenue and more importantly, what drives profit, and what are the predictors of integrated health system financial and economic performance. Learn how health care market dynamics impact clinical and business models and how value can be created in health systems.

Sunday–Tuesday • April 26-28

Physicians and Hospitals: Proven Techniques to Optimize the Relationship

ACPE’s Keystone: The Blueprint for High Performance

$395ACPE members / $470 non-members • 7 CME credits

Edward O’Connor, MBA, PhD Too often it seems that physicians and health system managers are locked in a lose-lose battle with no apparent way out. This course will develop a new and non-intuitive approach for managing the often broken relationships between health system managers and physicians. Specifically, participants will:

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Review why traditional approaches for integrating hospitals and physicians frequently don’t work

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Examine specific strategies for developing connections among often disparate and fragmented individuals

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Apply tools for managing the relationships between critically needed, highly diverse health care perspectives

$1,525 ACPE members / $1,675 non-members • 24 CME credits (Graduate Degree Section 1 Elective)

Eric Berkowitz, PhD William Geary, PhD Roger Schenke Edward O’Connor, MBA, PhD

ACPE’s Annual Meeting

Sunday • April 26

The complexities of managing in today’s health care environment can be overwhelming. How do you pull it all together and manage successfully in keeping with your leadership vision?

• • • •

Increase productivity Cut costs Increase revenues Create loyalty

This intensive course deploys a dynamic team of instructors to help you develop your own personal blueprint for leading and growing your organization, department or agency. You’ll discover your own “true north” and emerge from the course with an effective framework for balancing competing disciplines and resources by utilizing top line strategies that impact the bottom line. This course was formerly titled “Leading Beyond the Bottom Line.”

ACPE.org/annual

ACPE’s Annual Meeting

Saturday–Sunday • April 25-26

Monday–Tuesday • April 27-28

Solve This! Breakthrough Thinking for Physician Executives

MetaLeadership: Removing Barriers and Building Bridges

$800 ACPE members / $875 non-members • 12 CME credits (Graduate Degree Section 1 Elective)

Kevin E. O’Connor, MA, CSP

Barry C. Dorn, MD, MHCM Leonard J. Marcus, PhD

Do you struggle with persistent problems? Do you need things to change? This course will provide physician executives with new ways to think, manage and lead. It will allow you a competitive edge as well as a cooperative edge with your colleagues. Participants will use real-world scenarios to expand their own thinking and that of their project teams.

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Foster visioning and innovation with a team of independent thinkers

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Take advantage of organizational mistakes, errors or failure to create solutions

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Get the right ideas from the right people with the right results

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Use strategic thinking to be a creative leader without being seen as a micromanager

ACPE.org/annual

This course was formerly titled “Creativity in Medical Management.”

With all the demands that go along with being a physician executive, it’s easy to develop tunnel vision. It takes a special kind of leader to look beyond department walls and pull together the best possible team to tackle a problem. We call these people “meta-leaders,” the men and women who can integrate the work of many different people to build quality patient care. This course will help you step back and learn how to identify and connect people from throughout your organization, regardless of their specialty or area of expertise. The popular course consistently draws raves from participants, and is taught by Barry C. Dorn, MD, MHCM, and Leonard J. Marcus, PhD, both from the Harvard School of Public Health.

Friday-Saturday • April 24-25

Managing Physician Performance:

Crucial Conversations® in Medical Management

Hiring and Retaining the Best Physicians for Your Organization $1,525 ACPE members / $1,675 non-members • 24 CME credits (Graduate Degree Section 1 Core)

William Martin, PsyD, MPH, CHES Jennifer Grebenschikoff Sue Cejka Timothy Keogh, PhD Physician performance affects critical elements of all health care organizations—nursing and ancillary staff retention, medical staff and medical group cohesion, even referring physician and patient retention. How can you help each physician fully contribute to the goals of your group, hospital, or practice? Learn how to:

• •

Find, evaluate and hire the best candidates

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Set, apply and evaluate clear expectations and measures of performance

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Use routine and periodic feedback to make marginal performance and adverse action the exception rather than the rule

Design and implement compensation plans aligned with your organization’s expectations

$800 ACPE members / $875 non-members • 14 CME credits (Graduate Degree Section 1 Elective)

Stacy Nelson Are the managers and staff at your health care organization unwilling or unable to effectively address and resolve sensitive, controversial, or high-stakes issues? Crucial Conversations® can help.

ACPE’s Annual Meeting

Friday–Monday • April 24-27

Based on more than twenty-five years of research, Crucial Conversations® asserts one thing: if you can transfer skills that top performers routinely use to effectively handle controversial issues, then you can create more positive results across an entire organization. Participants in this popular course will notice significant improvement in:

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Performance Appraisal — talk honestly and openly no matter how delicate the topic

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Teamwork — reach agreement on how to work together and treat all members with respect

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Relationships and Diversity — work through differences with others and strengthen relationships

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Patient Safety and Quality — discuss violations and solutions without finger-pointing or resentment

Individual and small group exercises offer you the opportunity to apply what you’ve learned about:

• • • •

Defining expected behaviors and outcomes Measuring performance against expectations Giving and receiving feedback Managing the marginal performer

Designation

The American College of Physician Executives (ACPE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing education for physicians.

The American College of Physician Executives (ACPE) designates this educational activity for a maximum of 197 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

ACPE.org/annual

Accreditation

ACPE’s Annual Meeting

Friday–Sunday • April 24-26

Leadership and Governance

for Group Practice Board Members

On the Frontline! Leadership & Management Skills for Department Heads

$870 ACPE members / $945 non-members • 18 CME Credits

Jamie Orlikoff, MA William Martin, PsyD, MPH, CHES Mark Covaleski, CPA, PhD Michael Guthrie, MD, MBA

Robert Marder, MD William Martin, PsyD, MPH, CHES Timothy Keogh, PhD Mark Covaleski, CPA, PhD Michael Guthrie, MD, MBA

Learn the governance skills you need to build consensus and lead with confidence. Group practice board members will gain invaluable information and tools during this “hands-on” educational experience. With our faculty experts, you’ll learn to make the decisions that will move your group ahead of the competition.

ACPE.org/annual

Friday–Sunday • April 24-26

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Leading at the board level: Governance vs. Management

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Identifying the key responsibilities of board members, particularly in quality management and error reduction

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Reconciling generational issues of your partners and associates

• • • • •

Getting the financial reports that really matter Controlling costs and increasing revenue sources

Running a modern-day clinical department not only requires leadership skills but also management competence — not unlike running a complex business.

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Better understand and balance the dual roles of clinician and administrator

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Strengthen vital workplace communication skills

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Gain a clearer understanding of your organization’s finances

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Use group dynamics and organizational politics to your advantage

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Foster a culture of quality and patient safety

Evaluate and influence physician behavior, particularly the disruptive behavior that causes you such stress

Establishing performance and behavioral standards Managing disruptive and impaired physicians Running more effective board meetings

This course was formerly titled “Leadership & Management for Hospital Department Chairs.”

Friday–Tuesday • April 24–28

Core competencies in the business side of medicine $1,475 members / $1,550 non-members • 35 CME credits (Graduate Degree Section 1 Core / Elective)

These days, it isn’t enough to be a good doctor. Whether you’re working in a group practice or hospital, in insurance or any other health care setting, you need business know-how and vital skills if you want your organization and your career to thrive.

ACPE’s Annual Meeting

Physician in Management Seminar

Finance / Marketing / Negotiation / Communication / Management / Influence Choose your own track! Take the full 6-module course (above) or select the individual modules described below. (You will save $130 by attending the full 6-module seminar.)

Choose the entire five-day/six-module seminar, or select individual modules. Finance in Health Care Organizations

Valuable Communication Skills

Hugh Long, MBA, PhD, JD

Timothy Keogh, PhD

Learn key financial concepts and basic economic principles that will earn you respect from administration and admiration from clinicians.

Build solid communication skills that are required to gain influence, promote cooperation and engage top performers.

Friday, April 24 • 7 CME credits

$160 ACPE members / $170 non-members

$320 ACPE members / $335 non-members

Monday morning, April 27 • 3.5 CME credits (Graduate Degree Section 1 Elective)

(Graduate Degree Section 1 Elective)

Marketing and Strategic Planning

Management Skills

Eric Berkowitz, PhD

Michael Guthrie, MD, MBA

Understand techniques for marketing health care and staying ahead of the competition including differential advantage, target markets and relationship marketing.

Master the tools for effective decision-making, group dynamics, running meetings, dealing with disruptive individuals, and other every day challenges in management.

Monday afternoon, April 27 • 3.5 CME credits

$320 members / $335 non-members

$160 ACPE members / $170 non-members

(Graduate Degree Section 1 Core)

(Graduate Degree Section 1 Elective)

Powerful Negotiation Skills

Increasing Your Influence

Linda Babcock, PhD

Charles Dwyer, PhD

Learn proven techniques to use in every negotiation process and come out further ahead than you ever thought possible.

Recognize how power, authority and perception play an active role in influencing individual and organizational behavior.

Sunday, April 26 • 7 CME credits

(Course ends at 12:30 pm with a take-home assignment)

$320 ACPE members / $335 non-members

(Graduate Degree Section 1 Core

(Graduate Degree Section 1 Core)

Tuesday, April 28 • 7 CME credits

ACPE.org/annual

Saturday, April 25 • 7 CME credits

ACPE’s Annual Meeting

Annual Meeting Agenda Friday, April 24

Sunday, April 26

7:00am-8:00am

Continental Breakfast

6:30am-8:00am

Continental Breakfast

8:00am-4:30pm

Best Practices in Managing a Hospital Medicine Program Crucial Conversations Leadership & Governance for Group Practice Board Members Lessons in Leadership Managing Physician Performance On the Frontline! Leadership for Department Heads Physician in Management (Finance)

7:00am-7:50am

Breakfast Discussion for Women in Medical Management

7:00am-12:30pm

Solve This!

7:15am-7:45am

Non-denominational Worship Service

8:00am-12:00pm

Leadership & Governance for Group Practice Board Members On the Frontline! Leadership for Department Heads

11:30am-1:00pm

34th Annual Meeting of the Members

4:45pm-5:45pm

Keynote Speaker: Peter Athans

6:00pm-7:00pm

Welcome Reception

8:00am-4:30pm

ACPE’s Keystone Managing Physician Performance Physician in Management (Negotiation) Physicians & Hospitals Vanguard Program

12:00pm-12:45pm

ACPE Update: Master’s Degrees

ACPE.org/annual

Saturday, April 25 6:30am-8:00am

Continental Breakfast

Monday, April 27

7:00am-7:50am

VIP Breakfast for First Time Participants

6:30am-8:00am

Continental Breakfast

7:00am-12:30pm

Managing Physician Performance

7:00am-12:30pm

Managing Physician Performance

8:00am-4:30pm

Leadership Summit: Reaching Your Goals, Recapturing Your Passion

Vanguard Program

Crucial Conversations Leadership & Governance for Group Practice Board Members On the Frontline! Leadership for Department Heads Physician in Management (Marketing) Solve This!

8:00am-4:30pm

ACPE’s Keystone MetaLeadership: Removing Barriers & Building Bridges Physician in Management (Comm/Mgmt)

9:30am-10:30am

Spouse/Guest Function

5:00pm-6:00pm

Cocktail Reception

9:30am-10:30am

Spouse/Guest Culinary Function

Tuesday, April 28

12:15pm-12:45pm

ACPE Update: Credentials in Medical Management

6:30am-8:00am

Continental Breakfast

5:30pm-6:00pm

Cocktail Reception

6:00pm-9:00pm

Induction Celebration

7:00am-12:30pm

ACPE’s Keystone MetaLeadership: Removing Barriers & Building Bridges Physician in Management (Influence)

ACPE’s Annual Meeting

Hyatt Regency Chicago

151 East Wacker Drive, Chicago, Illinois 60601 312-565-1234 $219/night + current state sales tax (ACPE rate valid until March 26, 2009 or until the block of rooms sells out, whichever comes first) Located in the heart of the city, the Four Diamond Hyatt Regency Chicago is just steps away from the acclaimed “Magnificent Mile,” Michigan Avenue’s toniest stretch with leading stores.

It’s also within walking distance of many of Chicago’s premier landmarks and cultural attractions. Chicago Architecture Foundation River Cruise – The best of the boat cruises that ply the Chicago River, the Chicago Architecture Foundation’s river tours provide knowledgeable narration of 50 distinctive buildings in popular 90-minute outings.

Loop Public Sculpture – A few blocks in Chicago’s Loop district comprise an outdoor exhibit space devoted to some of the world’s finest sculptors – Pablo Picasso, Joan Miro, Marc Chagall.

s The Rookery – Designed by Daniel Burnham and John Wellborn Root in the 1880s, and later renovated by Frank Lloyd Wright, the Rookery is among Chicago’s most admired landmarks.

Sears Tower – Although it is no longer the world’s tallest building, the Sears Tower rises higher than any other structure in the city. As well as unique and stylish architecture, it has the highest manmade vantage point in the western hemisphere.

More to see Carson Pirie Scott & Company Building Chicago Cultural Center James R. Thompson Center

Marquette Building Museum of Contemporary Photography

Printer’s Row Spertus Museum of Judaica

ACPE.org/annual

To register for the ACPE Annual Meeting call 800-562-8088 or visit ACPE.org/annual

ACPE Annual Meeting: Hyatt Regency Chicago While youâ&#x20AC;&#x2122;re in Chicago, be sure to visit ACPEâ&#x20AC;&#x2122;s patrons. Representatives will be on hand to offer useful advice and explain their products and services to ACPE members.

Patrons include: Cogent Healthcare Ingenious Med Phytel Pine Grove SBTI Thomson Reuters Zynx Look for their displays near the ACPE Information Center.

In addition, a few select patrons will be offering bonus sessions, where speakers will discuss topics of interest to participants. Mark them on your calendar now! *Pine Grove: 4:45 p.m.-5:15 p.m. Saturday, April 25 * Zynx: 7:15 a.m.-7:45 a.m., Sunday, April 26 *SBTI: 4:45 p.m.-5:15 p.m., Sunday, April 26 *Thomson-Reuters: 7:15 a.m.-7:45 p.m., Monday, April 27 *Cogent Healthcare: 4:45-5:15 p.m., Monday, April 27.

Compensation

Physician Executives Beware: Your Pay May Be Reported David Bjork, PhD Senior vice president and senior consultant at Integrated Healthcare Strategies in Minneapolis, Minn. david.bjork@ihstrategies.com

The redesigned form 990 requires organizations to report compensation for many more employees. The new form also requires more detailed reporting than in the past, and the rules are clear enough that we can expect more consistent and more complete reporting of total compensation.

Whose pay is reported on the new form 990? We’ve all seen local newspaper articles discussing the pay of top-level corporate and hospital executives. In the past, physician executives have not had their compensation exposed to the public in this way unless they were hospital CEOs or COOs. But that is changing. Beginning this year, hospitals and health systems will be required to provide the IRS with more details of pay packages for a larger group of employees, a group that is likely to include high-ranking physicians in executive and clinical positions. And because reports to the IRS are public information, the details contained in them may become public knowledge. Is your pay about to be exposed to the general public? If it is reported, are you prepared to answer questions from the media, your friends and colleagues, and your subordinates?

What is form 990? Form 990 is an annual report filed by tax-exempt organizations with the IRS in lieu of a tax return. Form 990 is public information, and must be made available to the general public, including the press. Many organizations post the form on their Web sites, and the IRS posts returns on GuideStar, a searchable Internet database. Form 990 has always required reporting of executive pay. But in the past, reporting was limited to a few executives, and the rules were vague enough that it wasn’t altogether clear what needed to be included. The end result was that comparisons between organizations were difficult to make. In 2007, the IRS announced a redesign of form 990, the first in over 30 years. Final rules for the new form were published in August 2008 and will take effect with forms filed in 2009 covering 2008 activities. 70

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If you are the chief medical officer of a hospital or health system, or if you have an officer’s title or serve on the hospital’s board, your pay may need to be reported, no matter what it is. If you receive $150,000 or more in W-2 income plus benefits, you should expect your pay to be reported if you are a “key employee” who manages a “discrete segment or activity of the organization that represents 10 percent or more of the activities, assets, income, or expenses of the organization.” If you are the medical director or chief of service for a major service line, you may fall into this category. If you are paid $100,000 or more in W-2 income, you should expect your pay to be reported if you are among the five highest compensated employees other than officers, directors, trustees, and key employees; or if you have held an officer’s title or served on the board or met the definition of a key employee any time in the last five years. This group is likely to include clinical physicians employed by hospitals, as well as physician executives. If you have served on the board in the past and receive a pension or deferred compensation of $10,000 or more each year related to your board service, you should expect this to be reported. If you meet any of these requirements for reporting, and also receive compensation from another organization (a clinical practice, for example) that provides services to your tax-exempt employer, your pay from both organizations will be reported on form 990.

What pay will be reported? If you fall into one of these categories, your W-2 income from the tax-exempt organization and any related organizations will be reported on part VII of form 990, along with an

estimate of any other compensation (i.e., non-taxable benefits or deferred compensation) you receive from those organizations. Your pay will also be reported in more detail on Schedule J. Your W-2 income will be reported and split between salary, bonus or incentive pay, and other taxable pay such as perquisites (car or car allowance, club membership, etc.). Any deferred compensation you receive, such as nonqualified retirement plan contributions, will be reported in the fourth column. The value of your non-taxable benefits will be reported in the fifth column. These sums are added together in the sixth column, and the seventh column shows any amount of the total that has been reported on form 990 in a previous year. The seventh column is necessary because deferred compensation must be reported twice: once when it is earned, and again when it is paid. Pay from your tax-exempt employer is reported on line (i), and pay from a related organization such as a clinical practice is reported on line (ii).

Figure 1: Schedule J

What should you do if your pay is going to be reported? If you think you fall into one of the categories of employees whose pay must be reported on form 990, you don’t need to panic. There are several things you can do to prepare for the questions your friends and colleagues may ask. First, become familiar with your employer’s compensation philosophy. This philosophy will spell out how executives’ pay and benefits compare to those of other similar organizations, and it will describe or name the organizations it uses for these comparisons. It will describe the impact of the incentive compensation plan on the competitiveness of your pay package. It will tell you whether decisions about your total compensation package are made by the board as a whole, an

executive compensation committee, or the CEO. Secondly, review your bonus or incentive plan and be prepared to explain, in general terms, how it works. For example, you may want to explain that a sizeable amount of your cash compensation is paid to you only if the organization achieves certain objectives, such as improvements in quality or patient satisfaction. Thirdly, be prepared to answer questions like, “Why are you paid more than I am?” You may want to refer to the executive compensation philosophy to explain how your pay compares to other physician executives who hold similar positions in similar organizations.

Tell your human resources executive you don’t want to be surprised, but want to be notified of what will be published, and when. Ask if your organization has appointed a spokesperson to deal with questions from the media. You should not answer questions from the media about your own compensation, and your employer will not expect or want you to do that. The most important thing to remember is that reports about executive pay always get people talking, but the effect never lasts very long.

ACPE.ORG

Ethical Aspects

Hospital Chaplains: What, Who, and Why? Richard E. Thompson, MD Former vice president of the Illinois Hospital Association, author of Think Before You Believe, Xlibris, 2005. tmaret@sbcglobal.net

Even if religion is not usually important to a person, he or she may feel a need for spiritual support in time of health care crisis. Such a person is quite vulnerable. If they do not have a respected clergyperson in their lives, we must be sure that the person we provide will observe the same cardinal principle observed by physicians, primum non nocere.

Certification …the desire of chaplains to strengthen their profession…to more clearly define their work and to establish agreed-upon standards of practice for those eligible to be called “chaplain”…is a predictable stage in the natural history of an occupational group.1 Health care leaders, especially in the hospital branch, pay big bucks to consultants for help with winning physician support.2 On the other hand, chances are we don’t pay much attention to the Office of the Chaplain. Indeed, we probably harbor some old, obsolete notions about chaplains. For example, in my clinical practice days hospital chaplains were often retired ministers with no special additional credentials. Not anymore. A recent series of articles in The Hastings Center Report opened my eyes to what is going on with hospital chaplains these days,3 and stimulated my interest in the following questions. If you haven’t done so lately, why not ask your chaplain to lead a discussion of these questions and others he or she might suggest in an educational program for executive staff, board, medical staff, nursing staff, and other hospital employees? What is a chaplain? A chaplain is an ordained and specially qualified member of the clergy officially associated with a workplace such as a military base, prison, or hospital. Should we credential chaplains? The purpose of credentialing physicians is to protect people from a dangerous (marginally competent or impaired) practitioner. Our mind set should be that, at least in the case of some people, a marginally competent or impaired chaplain can be just as dangerous. 72

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Is there a certification program for chaplains? Yes, ministers can now become certified chaplains. However, this is a relatively recent development. So be careful here. That is, again think about your physician credentialing experience. Providing credentials to physicians has become a cottage industry. A board-certified orthopedist might have passed the rigorous exam given by the American Board of Orthopedic Surgery, or he might have purchased his certificate from some certificate mill. A certified chaplain might be certified by (another) ACPE, the Association for Clinical Pastoral Education. 4 In that case, the certified pastor’s qualifications include, among other things, “...at least 1600 hours of supervised clinical pastoral education training in an accredited, hospital-based program.” 5 On the other hand, the certified chaplain might have bought a certificate from a source found online that charges less than $100 and throws in a bonus coupon good for discount rates at some hotels. Anyone interested in being a chaplain is invited to buy a certificate. Who is a chaplain? What personal characteristics and interests does a good chaplain exhibit? I asked a couple of chaplain friends to answer this one. According to them a good chaplain must be caring, compassionate, a good listener, and professional in demeanor; must have a strong sense of accountability in an earthly sense as well as to God, and must be blind to race, creed, color, sex, and social status. A good chaplain is not an evangelist. Except where religious owners of a hospital insist otherwise, the chaplain’s goal is to respect the patient’s/family member’s beliefs, not impose his or her own.

From some of my own experiences as a practicing physician, I add: A chaplain must not be a wannabe doctor. He or she should refrain from trying to discuss a patient’s medical diagnosis and treatment plan. From the physician’s viewpoint, nothing is worse than having a family upset because a well-meaning chaplain or visiting local clergyman waltzed in to a patient’s room, asked a few questions, then said, “He has ordered that? Well, I know my Aunt Matilda had the same thing and that is not what they did for her at all.” A good chaplain will understand and accept the fact that some people simply do not need a chaplain’s services. If people are adequately supported by friends, family, and their own pastor and religious affiliation, then repetitive calls or visits from a chaplain can be intrusive.

Ethical conduct Is there an ethical code for hospital chaplains? Yes. Indeed, there are probably several. One good example is the Code of Ethics of the Association of Professional Chaplains (APC).6 The Code includes:

• Members shall affirm the religious and spiritual freedom of all persons and refrain from imposing doctrinal positions or spiritual practices on persons whom they encounter in their professional role as chaplain. • Members shall follow the policies of their employing institution regarding patient confidentiality, sharing private information about those whom they serve only according to those policies, the member’s religious tradition, or as required by law. • Members shall maintain an active relationship and good standing within the faith communities in which they are ordained, commissioned, or endorsed.

References 1.

De Vries R, Berlinger N and Cage W. Lost in Translation: The Chaplain’s Role in Health Care. Hastings Center Report, November/ December 2008; 38(6): 23-7.

Thompson R. Keys to Winning Physician Support: Real Winners Don’t Gag the Good Guys. ACPE. Tampa, Fla. 1998.

The Hastings Center Report, NovemberDecember 2008; 38(6). 5 articles on the Chaplaincy.. The Hastings Center, Garrison, N.Y. (www.thehastingscenter. org), is an independent, non-partisan, non-profit bioethics research institute founded in 1969.

Association for Clinical Pastoral Education, Inc. www.acpe.edu

Jacobs MR. What are we doing here? Chaplains in contemporary health care. The Hastings Center Report November-December 2008; 38(6):15-8

6. www.professionalchaplains.org And here is one that makes chaplains and physicians truly kindred souls. Altogether now, let’s hear one big collective groan: • Members shall maintain accurately and currently any patient records… or other documents required in the course of their work.

A chaplain must not be a wannabe doctor. He or she should refrain from trying to discuss a patient’s medical diagnosis and treatment plan. ACPE.ORG

Careers

Are You Considered A “High Potential?” Bill Tiffan Principal at T2 Management Consultants in Atlanta, Ga. bill@t2-consultants.com

In my last column (The Physician Executive, Jan/Feb 2009) I wrote an article entitled “What Do You Want To Be When You Grow Up?” In it, I recommended that we not allow our careers to manage us—we must manage them. It is in the spirit of managing our careers that I want you to consider a very important concept—leveraging your potential to the fullest for greater job satisfaction and productivity to get through the current economic downturn. It should come as no surprise that, during our current economic crisis, organizations are seeking ways to cut expenses and programs in an effort to survive. Often one of the first casualties of belt-tightening is people development. In fact, a recent survey of 62 U.S.-based corporate talent and HR chiefs, confirmed this trend. Results of that survey indicated that companies “can’t afford to take risks with their best talent, who represent the key to recovery,” said Steve Krupp, partner and leader of the Executive Talent Management practice at Delta Organization & Leadership, a division of Oliver Wyman Management Consulting. “Yet this research suggests that these future leaders in many cases don’t even know who they are. Too often they are not receiving the communication, attention, or development to give them confidence about their future. As executives put their heads down to grapple with uncertain times, plunging stock prices, and frozen markets, they can’t forget their high-potential talent, who may also be seeking their own bailout plan.” We are in a period when leaders and potential leaders need to step up to the plate, and be very proactive about making a difference in the organizations they lead. Rather than keeping one’s head down and “just doing what’s expected,” the best performers need to rise to the occasion and 74

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contribute in significant ways to ensure the organization will thrive and not just survive. What these difficult times call for is a determination to win, the will to succeed and the passion to push through obstacles to solve the problems that threaten to derail the organization. That brings us to our topic of high potentials. The challenges of today do not only underscore the responsibility of executive leadership, but also provide a great opportunity for those with untapped potential to make a difference. The word “potential” comes from the Latin word for “power.” It means “existing in possibility; capable of development into actuality; a power or quality that has not yet come forth but may emerge and develop.” We can then define a “high potential” as an individual with something special hidden in their lives that, under the right conditions, could emerge and be leveraged for greater success. This raises several questions: • What is your potential? • How high is it? • How can you use it to your advantage? Unfortunately, many people struggle with their potential and often understate their abilities. When faced with the messages from success-oriented seminars and books that cheer us on to “realize our full potential,” “be all you can be,” etc. they shrink back in some despair because they: • Were told from childhood that they can’t or shouldn’t be what they want to be • Have negative views of themselves • Have no role models who have tapped into their real potential and succeeded • Have a belief system that limits their potential • Are discouraged because they have occasionally failed and didn’t learn from their mistakes

Potential leaders need to step up to the plate, and be very proactive about making a difference in the organizations they lead.

• Are afraid of stepping outside their comfort zone and taking risks in unchartered areas of life Our experience in coaching people with high potential indicates that companies see something in certain people that indicates the possibility for achieving bigger and better things. These organizations want to tap into that potential and channel it so that the individual can contribute in more substantial ways as a future leader of the organization. Here’s a partial list of key indicators senior leaders saw in individuals they considered to be “high potentials:”

Positive attitude, a “can do” attitude—People who demonstrate high potential show it first in their attitude, secondarily in their actual performance. Who wants to be led or influenced by a critical, negative person?

The attitude indicates “I can do more,” “I can be more than I am now.”

Focused, priority-driven—They know what they want and how to get there and are determined to make it happen. Nothing can stand in their way. No obstacle is too great. They live by their priorities and rarely stray from attending to them.

Performance-oriented—High potential always includes high performance. We often do “live 360s” to gather feedback on individuals by interviewing their boss, peers and direct reports. Well into the interview it sounds like the individual is a very strong leader until we ask, “What significant contributions has this person made to the organization?” It’s surprising how often we hear “Gee, I can’t really think of anything significant. He does his job. He makes his numbers. But

nothing stands out.” People with high potential reveal that potential through the contributions they make, regardless of whether it’s part of their job description or not.

Future-oriented—High potential individuals are attracted by the organization’s long-range plan and the challenges to be faced in accomplishing strategic objectives. When asked why someone is considered to be a high potential we often hear that they are future-oriented and show a keen interest in where the organization is headed and want to be involved in helping it get there. This shows up in attitude, performance and priorities, -which, together with their skills, will enable them to achieve great things.

Demonstrated skills in mission-critical areas of the organization—These skills could be technical, interpersonal, ACPE.ORG

Hope is not a strategy—action is. knowledge-based or any combination of the above. Notice we are saying “knowledge-based skills” as opposed to just “knowledge.” It’s not what you know that counts as much as what you do with what you know. There are plenty of smart people out there who fail to use their intelligence and knowledge to advance the organizational objectives.

Leadership potential—This often misunderstood and misapplied concept is an umbrella term used to describe highpotential employees. It assumes that the individual will move up in the organization as a leader or manager. It’s important to note that being a high potential does not have to carry with it the career path to management. “Leadership” as used here can include technical or thought leadership in the organization. There are many individuals who lack other important characteristics needed by people managers (e.g., interpersonal skills, planning skills) but who have great potential to contribute significantly to the organization in other ways such as research, sales, finance, information technology, etc. We seldom see people

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labeled as “high potentials” if they lack any of the following: • Ability to influence others through logic and data and/or through connecting with people emotionally • Proactive mindset, a self-starter with lots of initiative • Results-oriented and not satisfied with just talking about ideas; wants to make things happen and achieve goals • Energetic, passionate with a “fire in the belly” • Understands and practices collaboration; is a good team player

Willingness to take risks—This shows the individual is not satisfied with the status quo and is willing to move out of his or her comfort zone to get the job done. Willingness to take risks is often connected to a positive, can-do attitude. Negative people rarely are risk takers. With this understanding of the key indicators, how do you stack up?

Do you know yourself well enough to assess yourself against these criteria? A good place to begin is to turn the key indicators into questions for your self.

Attitude: Ask your friends and family about the attitude you project since it’s very difficult to assess this about yourself objectively. Do you tend to see the bright side of things without being unrealistic or superficial? Do you encourage creative thinking or do you tend to view all solutions as variations of previous approaches that failed?

Focus: Are you able to zero in on what needs to be done, what’s important and what is mission critical? Or do you tend to be scattered and to struggle with the tyranny of the urgent versus the important? Learning to set and live by priorities is the hallmark of high potentials.

Future: Do you look forward to what lies ahead? Do you want to be a part of shaping the future in your area of expertise?

Performance: List significant contributions you have made in each organization and in each job you have held for the last 10 years. Would others see them as significant? What impact have

you really made and how recently?

Skills: Are your skills relevant to the organizationâ&#x20AC;&#x2122;s future? If some of them are not, what are you doing to retool yourself? Have you or can you expand the application of your skills to new types of projects that align with the organizationâ&#x20AC;&#x2122;s strategic objectives?

Leadership: Do you consistently act

learning and the cycle continues. So as you consider the economic crisis in which we are immersed, use it as an opportunity to tap into your real potential and contribute in new ways to your organization. Rather than hunkering down and hoping for better days, do all you can to make those better days happen sooner rather than later. Hope is not a strategyâ&#x20AC;&#x201D;action is.

like a leader or more like a follower? Do you seek to influence others to achieve goals? Are you proactive and passionate about what you do? Do you get results? Are you by nature a collaborative person? Could you be?

Risk-taking: Are you secure enough in your own skin to step out of your comfort zone? Have you increased the boundaries of your comfort zone over the past few years?

Many paths to take As stated earlier, not all high potentials will become leaders and managers. Some will demonstrate their potential by extending themselves into new applications of their skills. A researcher might branch out to other types of research or investigate innovative technology in their current field. A hospital administrator might reveal a potential for influencing others more broadly by offering to teach a seminar or serve on a panel at an annual meeting of health care administrators. The key is that, once the skill is applied in a new situation or is augmented with additional training, the potential for greater contribution increases. As the contribution increases, the potential increases with the addition of those results. It is an ever-expanding cycle of learning, applying what is learned and perhaps taking a risk in doing so, and seeing the impact. That satisfaction of making an impact motivates more ACPE.ORG

Leadership

Do You Have CEO Disease? Breathe deeply Manya Arond-Thomas, MD President and chief catalyst of Heart of Healthcare, LLC, which specializes in leadership coaching, team building and change facilitation. heartofhealthcare.com

How frequently do you hear about yet another hospital system needing to cut millions of dollars out of its budget immediately? A physician executive was telling me recently how the health care system in which he works had gone from making money to suffering a substantial loss in a relatively short period of time, resulting in a mandate to cut tens of millions out of the budget. The organization has made sizable investments over the past few years in training to drive quality improvement and consulting for an organization-wide culture change initiative. But in the face of short-term losses, as is so often the case, these initiatives have already met their fate on the chopping block. Since both initiatives were incomplete in the implementation, ongoing investment in these very things that had been determined to be critical for a successful future are still exactly what’s needed to move forward to that future. As an executive coach, I couldn’t resist asking the physician executive if his boss had had a coach. To my surprise, my colleague said “Yes”, at which point I asked if 360 feedback had been an integral part of the coaching process. Once again, my friend said “Yes, but he wouldn’t listen to it.” Such is the nature of CEO disease. In order to be persistently successful, people and organizations need to adapt continually to their environment. This requires information from the environment. The more active and open the feedback loops, the more effective and efficient the adaptation and change can be.

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Feedback is like oxygen to a system. An organization is a living system and just like oxygen, all living systems need feedback in order to flourish. The measurement of patient satisfaction, employee satisfaction, even physician satisfaction is fairly universal. So why do we not routinely measure satisfaction with leadership? As we know from the Sears Employee-Customer Profit Chain study,1 the behavior of leadership is what drives 50 to 70 percent of employee satisfaction, which drives customer (patient) satisfaction and 20 to 30 percent of the bottom line results. It’s as if we assume that donning the cloak of leadership confers some state of perfection or super-human prescience. Yet, Collins, in Good to Great, 2 documented that Level 5 leaders, in fact, have an attitude of humility as well as ferocious resolve and fearlessness—all qualities that enable leaders to solicit and respond to feedback. When we look at organizations there is a pandemic of feedback-poor environments, and the problem only worsens when it comes to leaders receiving helpful feedback, specifically about their own performance. What better way for top leaders to assess their own performance than by getting feedback? And this feedback should address their leadership style, their behaviors and actions, their impact and their results.

What is CEO disease? CEO disease is the information vacuum around a leader that gets created when people, including his or her inner circle, withhold important (and usually unpleasant) information. This leaves the leader being out of touch and out of tune. This condition can also be true for other leaders within the organization, not only the CEO. (The term was first coined by John Byrne in an article in Business Week in 1991, and later described in the book Primal Leadership.3) Since a leader’s first task is to uncover the truth and an organization’s reality, CEO disease can be fatal, both to the

individual leader and to the organization. Leaders who are women or from a minority group generally get less useful feedback about their performance than do men. And top executives typically get the least reliable information about how they are doing. Why don’t leaders get the feedback they need? Typically, they don’t build the kind of relationships or organizational culture that results in deep dialogue about what’s working and what is not. Sometimes, when the leader has a commanding or pacesetting style, people are reluctant to share negative information for fear they will be shot as the messenger. These two leadership styles—for which the moniker is “Do as I do or tell you to do”—with their emphasis on outcome, can overlook process and the impact of their style. If leaders have this kind of blind spot, they don’t see the gold available to them in getting feedback frequently. Many subordinates as well as peers want to appear upbeat and optimistic and don’t want to be the one to rock the boat. And the more personal the message is, the less chance it has of getting delivered at all.

CEO disease is the information vacuum around a leader that gets created when people, including his or her inner circle, withhold important (and usually unpleasant) information. This leaves the leader being out of touch and out of tune.

How to get feedback The most successful leaders actively seek out negative feedback as well as positive. They let it be known that they are open to receive critiques either of their ideas or their leadership style. Almost all successful leaders are adept at self-assessment and seek out self-directed learning opportunities through mentoring, coaching, or other leadership development tools and methods. One way to get feedback is to simply ask for it from people whose feedback would be useful to you, including folks on the front lines, middle managers, peers, and supervisors. If you are asking for feedback on your leadership style, you want to ask people whom you know will be comfortable in being honest with you. Here are some questions you can ask: • What do you see as my strengths?

• What do you see as my opportunities for development/improvement? • What do I need to learn to be/do in order to be more effective? • What could I do more of? Less of? • If there were one thing you’d like me to do differently, what would that be? Since subordinates can feel put on the spot when their boss asks for feedback (and they aren’t always sure of what the consequences will be, especially if your leadership style hasn’t previously invited feedback), it can also be extremely useful and helpful to enlist an objective third party to solicit 360 data. This can be done through an assessment instrument or through interviews. Since the data are typically aggregated and anonymous, sometimes this is the only way that leaders can get honest feedback and see their blind spots.

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This was the case with one leader I coached, whose pacesetter style had gotten him promoted to turn around a troubled high-profile product development team. Yet his drive and high expectations exacerbated existing team morale issues and productivity. Using the data from a 360 assessment, he realized that: • He wasn’t doing as well as he had thought. • There were some things he needed to change. With that information, he was able to develop a more productive, participatory leadership style that reengaged his team. Staying mindful of learning opportunities when they arise and spontaneously seizing them is a hallmark of the emotionally intelligent leader. What inhibits growth and innovation, both personally and in organizations, are attachments to habits (what has worked in the past) and blind spots (which we all have). In order to survive in a rapidly changing environment, you must continually update what is working. Unless you get data about the quality and effectiveness of your interactions, you will become a prisoner of the status quo.

ACPE OnSite Programs will bring our expert faculty to your organization and customize a program specifically for your needs. ACPE will help you choose a topic and speaker, coordinate the travel logistics and provide Category 1 CME to your participants.

References 1.

Rucci A, Kirn S, Quinn R. “The EmployeeCustomer Profit Chain at Sears,” Harvard Business Review. January 1998.

Collins J. Good To Great, New York: Harper Collins, 2001.

Goleman D, Boyatzis R, McKee A. Primal Leadership, Boston: Harvard Business School Press, 2002.

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Have you scheduled your speakers for your next board retreat, leadership forum or physician leadership program yet?

For more information, contact Tracy Kennard at 800-562-8088, or visit www.acpe.org/onsite High Quality Medical Management Education

Delivered.

ACPEnews More changes to come

CEO's Corner

Call to Action — ACPE Needs You Now! By Barry Silbaugh, MD, MS, FACPE — ACPE CEO

ACPE has a new mission/vision statement: “The world’s premier organization for lifelong growth and support of physician leaders.” Coupled with our new tagline, “Inspiring physician leaders. Improving health,” the two statements convey a more focused message about what the College does and its goals for the future. Both the mission/ vision statement and the tagline were approved by your Board of Directors. Now comes the tough part. How do we build, grow, support, and inspire physician leaders? Whether you’re an experienced physician executive, or a young physician looking at possible career options, we want your help to grow the College in several specific areas. Think of whom you know personally who can help the College in these specific ways:

Both can be reached by phone at 800-562-8088.

Academic angle

Third, please let me know if you spot an opportunity for one of our Board members or Fellows to do a presentation on the powerful role that physicians with leadership and management training can play in improving health care. We’re putting the finishing touches on a presentation outlining what the College and its Members bring to the health care marketplace. If you know of a local or regional meeting where we could make this presentation, please email me at bsilbaugh@acpe.org.

First, in response to a growing chorus of voices calling for introduction of the College’s educational content on teamwork, leadership, quality, and high reliability to young physicians or residents, we would like the names of people you know in academic institutions and their accreditation bodies who would be receptive to this concept. Please email or call Charisse Jimenez (cjimenez@acpe.org) or Carrie Weimar (cweimar@acpe.org). 82

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Risk-takers wanted Second, we’d like two or three of you risk takers who want to share your enthusiasm to possibly be interviewed for an article or perhaps even help us build a workshop or course that appeals to physicians who are owners, entrepreneurs, or have a business idea they want to explore. Some of our university partners have special expertise in entrepreneurial thinking and are willing to help with this effort. Please contact Charisse Jimenez (cjimenez@acpe.org) or Carrie Weimar (cweimar@acpe.org). Both can be reached by phone at 800562-8088.

Speaking engagement

Finally, we’re making lots of changes around the College—some that you’ve probably noticed and others that will be coming soon. There's already a new look for the journal you're reading right now, and there's a new “Members in the News” section on our home page at www. acpe.org that highlights our members’ contributions to improving health in their communities, regions, and countries. A new course on the science of high reliability debuted at the Winter Institute and will soon be one of a dozen new InterAct courses planned for this year. If ever there is a time for physicians to step up to the plate and lead change in health care, it is now. Stay connected to the College as we move in this direction—together!

Annual Meeting 2009—The Year of New Beginnings at ACPE It’s a year of new beginnings for ACPE. To celebrate this, the College is featuring an exciting lineup of speakers, special presentations and new courses at its 2009 Annual Meeting at the Hyatt Regency Chicago, April 24 – 28.

The meeting begins on a high note on April 24th with a keynote address by Pete Athans. Known in climbing circles as “Mr. Everest,” Athans is an avid student of philosophy, poetry and prose and a frequent contributor to National Geographic Television. He has been on the summit of Everest more than any other western climber and was awarded the highest citation given by the American Alpine Club for his rescue of Beck Weathers in the 1996 Everest disaster.

The College also plans to honor Roger Schenke, who retired last summer after more than 33 years leading the College. The tribute will be held during the business meeting April 24th and at the ACPE/CCMM Dinner and Induction Ceremony on April 25th, where Schenke will be awarded honorary fellowship in the College.

The ceremony also features a presentation by Chuck Dwyer, longtime ACPE faculty and author of Shifting Sources of Power and Influence, one of ACPE’s top-selling publications.

Don't miss these new courses! Three new educational courses will debut at the Annual Meeting in Chicago, representing the College’s renewed commitment to providing physician executives the necessary training to create and manage safe, high-quality health care products and services. ACPE’s first Leadership Summit will be held on April 25th in conjunction with the other Annual Meeting events. The Summit will feature a “behind-the-scenes” conversation with Pete Athans as well as opportunities for self-assessment and participation in faculty- and peer-led workshops. Lessons in Leadership: Do You Have What It Takes? on April 24th is the perfect introduction for physicians entering, or thinking about entering, health care leadership. It’s also a great course for experienced physician leaders that goes beyond the refresher and equips the senior leader with an updated toolkit to take back home. Best Practices in Managing a Hospital Medicine Program, also offered on April 24th, focuses on improving existing or starting new programs in hospital medicine, the fastest-growing medical specialty in the U.S.

workshops feature superb faculty and relevant topics in personal and professional growth. Vanguard registration is open to experienced physician executives. Fellows, Certified Physician Executives or physician leaders holding advanced degrees in management.

And a new Vanguard, too! The Vanguard Program format is also new. This year’s program spans four days: April 24th – 27th. Come in Friday for the Meeting of the Members and the kickoff session with Peter Athans. On Saturday, enjoy the Leadership Summit and An Evening to Celebrate. Sunday and Monday ACPE.ORG

Members on the Move ACPE members advancing their careers Victor A. Collymore,

Allan T. Bombard, MD, MBA, is chief medical officer of Sequenom, Inc., in San Diego, California. Bombard oversees Sequenom's clinical and medical affairs, including clinical strategy, operations and clinical advocacy. Before joining Sequenom, Bombard was the chief executive officer of Lenetix Medical Laboratory of Mineola, New York. Prior to joining Lenetix, he was chief medical officer of Sharp Mary Birch Hospital in San Diego, the largest women's hospital in the western United States. Bombard received his undergraduate degree from Colgate University, his MD from the George Washington University School of Medicine and Health Sciences, and completed an MBA at the University of San Diego. He completed a residency in obstetrics and gynecology at the Wilford Hall USAF Medical Center in San Antonio, and his fellowship in Clinical Genetics at Northwestern University in Chicago. Bombard retired from the USAF Reserves in 2002 with the rank of colonel, and served in Operation Desert Storm. He is a Founding Fellow of the American College of Medical Genetics and a Fellow of the American College of Obstetricians & Gynecologists. He has lectured extensively on a variety of women's health issues including genetic counseling, prenatal screening and diagnosis, the business of medicine, and BRCA screening. His articles have appeared in peer-reviewed medical journals such as the Lancet and the American Journal of Obstetrics & Gynecology.

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MD, FACP, is the regional vice president of the PeaceHealth Medical Group (PHMG) in the state of Washington. Collymore is the leading physician executive for the 81 PHMG physicians providing care to residents in Bellingham and throughout northwest Washington. Collymore moved north from Seattle, where he spent the last six years as medical director over care coordinator at Group Health. Prior to that, he worked in Colorado and Los Angeles for Kaiser Permanente. Collymore received his undergraduate degree from Columbia University in New York City, and his medical degree from Columbia’s College of Physicians and Surgeons. He completed his internship and residency at Mount Sinai Hospital, also in New York. The PHMG is part of the PeaceHealth System with hospitals in Alaska, Washington and Oregon, and sponsored by the Sisters of St. Joseph of Peace. In addition to the PHMG, PeaceHealth Whatcom Region includes St. Joseph Hospital, a not-for-profit, full-service hospital, a diagnostic laboratory and a joint venture outpatient imaging service.

James Gerson, MD, FAAP, has joined Los Angeles County's Community Health Plan (CHP) as chief medical officer. Gerson brings a wealth of managed care experience to CHP, having served as a medical director for managed care health plans for the past 11 years. He most recently served as Health Net’s regional medical director for State Health Programs for Los Angeles County from 2006-2008. In this role, he interfaced with over 50 physician groups regarding utilization and quality of care concerns,

reviewed member appeals, grievances and quality of care complaints, redesigned the physician group report card, and co-chaired the Healthcare Effectiveness Data and Information Set (HEDIS) outreach initiative and pay for performance program. Gerson attended medical school at Thomas Jefferson University in Philadelphia, completed his fellowships at Children's Hospital of Philadelphia, University of Pennsylvania, and a post doctoral fellowship at the National Institutes of Health. He is board certified in pediatrics and pediatric hematologyoncology. He also has had extensive experience as a primary care provider in an underserved area.

Francisco Gutierrez, MD, MHA, MHS, is senior vice president for medicine and health sciences at Laureate Education in Baltimore, Maryland. Gutierrez is responsible for strategic leadership of Laureate International Universities' medical and health sciences programs, including 15 medical schools, 14 dental schools, 16 nursing schools, 21 physical therapy schools, and more than 20 health sciences programs located in 30 cities around the world. Gutierrez most recently served as chief consultant for Health Navigation LLC. Previously, Gutierrez was the director of the international health care consulting practice at PricewaterhouseCoopers, and he has served as vice president of the Harris Methodist Health System. Gutierrez earned his medical degree and a master's degree in health management from the University of Mexico. He also earned a master's degree in health finance from Johns Hopkins University. He serves as an adjunct faculty member at the McDonough School of Business of Georgetown University.

Steve Julian, MD, CPE, is vice president of medical affairs at Sentara Obici Hospital in Suffolk, Virginia. Julian is a graduate of Virginia Tech, Medical College of Virginia of Virginia Commonwealth University and completed residency training at Wake Forest University Medical Center in general and thoracic surgery. He practiced cardiothoracic, vascular and critical care surgery for 17 years

at Peninsula Regional Medical Center in Salisbury, Maryland, where he was immediate past president of the medical staff prior to embarking now on a career in medical management with the Sentara Healthcare System.

Obituary ACPE is saddened by the recent death of longtime faculty member John B. Coombs, MD, who taught in the College's Three Faces of Quality course. Coombs was lauded by his colleagues as a national leader in improving health care for underserved and rural populations through his work with the University of Washington's rural-health program. A past president of the Washington State Academy of Family Physicians, he was associate dean, and later associate vice president for medical affairs and vice dean for regional affairs for the UW School of Medicine's student-training programs in rural health, primary care and family medicine. He died at his Seattle home on Jan. 19. A family member said he had been diagnosed with a malignant melanoma. He was 63. Coombs' rural health career began in 1974 as a physician in Tonasket, Okanogan County, for the National Health Service Corp. He then practiced pediatrics and family medicine in rural Omak, also in Okanogan County, from 1979 to 1984, and he taught UW medical students community-based patient care there. Coombs created the Obstetrical Access Clinic, a project that lowered the once-high infant mortality in Pierce County. He also established the Pediatric Sexual Abuse Clinic at Tacoma's Mary Bridge Children's Hospital. In 1998, Coombs was the first holder of the Theodore J. Phillips Professorship in Family Medicine, funded by an endowment that supports medical-student training in family medicine, rural health and rural health-issues research. Coombs also led the medical school's graduate residency-training programs. A 1967 UW zoology graduate, Dr. Coombs earned his medical degree from Cornell University School of Medicine, where he also earned a master's degree in nutrition, in 1972. He completed his residency in family medicine and in pediatrics at the UW.

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At the Top of Their Game ACPE’s just-published book features 30 captivating profiles of successful health care leaders who’ve made a huge impact on the practice of medicine. Among the leaders included in this book are: a. Marcia Angell, MD, former editor-in-chief, New England Journal of Medicine b. Robin Cook, MD, author c. Robert S. Galvin, MD, MBA, director of global health care, General Electric d. John W. Rowe, MD, former chairman and CEO, Aetna, Inc. e. Donna Shalala, PhD, former secretary, U.S. Department of Health and Human Services

This must-read book provides insights into how the health care leaders advanced their careers and what they experienced when they made it to the top.

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Southern Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 SMA.org

USC MMM degree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Marshall.usc.edu/mmm

ACPE OnSite programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Carnegie Mellon MMM degree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Heinz.cmu.edu/mmm

ACPE.org/OnSite

InterAct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

University of Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

ACPE.org/InterAct

Global.ullinois.edu/physician

Tulane University MMM degree . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Certified Physician Executives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Hsm.tulane.edu

CCMM.org

ACPE Book: At the Top of Their Game . . . . . . . . . . . . . . . . . . . . . . . 87

ACPE Physician in Management Seminar . . . . . . . . . . . . . . . . . . . . 47

Acpe.org/publications

ACPE.org

ACPE 2009 Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49-61

ACPE Book: Practicing Medicine in the 21st Century . . . . . . . . . . 88 Acpe.org/publications

ACPE.org/Annual

ACPE Careerlink . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 ACPE 2009 Annual Meeting Patrons Hospitalist Management Resources, LLC . . . . . . . . . . . . . . . . . . . . . 62 Hmrllc.com

Cogent Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Cogenthealthcare.com

Acpe.org/career

Chart Your ACPE Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 ACPE.org

ACPE Fellowship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C3 Acpe.org/Fellowship

Thomson Reuters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

ACPE Live Institutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C4

ThomsonReuters.com/freedom.com

Acpe.org

Phytel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Phytel.com

PEJ MARCHâ&#x20AC;˘APRIL/2009

Application for ACPE Membership Licensed allopathic or osteopathic physicians are eligible for membership in the American College of Physician Executives (ACPE). No examination is required for membership. Annual dues are $250, plus a $30 processing fee. Please return this completed application along with payment of $280 (U.S. currency) to ACPE at the address below. Please type or print clearly or attach your primary business card.

Name

______________________________________________________________________________________________________ First Name

❒ MD

❒ DO

Middle (optional)

❒ Masters/Management Degree_____________________

Last Name

Date of Birth: ________________

Nickname ________________

Primary Position and Organization Information I currently hold the position of ________________________________________________________________________________________________ I have held this position since ______________________________. I devote approximately _______% of my professional time to this position. Organization ______________________________________________________________________________________________________________ Organization Address _______________________________________________________________________________________________________ City/State/Zip/Country_______________________________________________________________________________________________________ Phone ____________________________ Fax ________________________________ Primary E-mail Address ______________________________ ❒ Please send all correspondence to the above address. ❒ Preferred mailing address __________________________________________________________________________________________________ City/State/Zip/Country ____________________________________________________________________________________________________ The single best category for the above organization is: (please choose only one) ❒ ❒ ❒ ❒

Hospital # of beds ____________________ Group Practice # of physicians ___________ Managed Care # of enrollees _____________ Ambulatory Care Center

❒ ❒ ❒ ❒

Physician/Hospital Organization Insurance Company Academic Health Center Government

❒ ❒ ❒ ❒

Industry Health System Military Review Organization

❒ ❒ ❒ ❒

Consulting Contracting/Staffing Services Entrepreneur Pharmaceutical Company

Briefly describe the above organization __________________________________________________________________________________________ Primary Specialty ________________________________________________________________________

Board Certified?

Medical School _________________________________________________________________________

Year Graduated __________________

Name

City, State, or Foreign Country

❒ Yes

❒ No

Reason for joining ACPE ____________________________________________________________________________________________________ Referred by ______________________________________________________________________________________________________________ To better serve our members, we ask you for the following information: Gender:

❒ Male

❒ Female

Select your race or ethnicity: ❒ American Indian or Alaskan Native

❒ Asian or Pacific Islander

❒ Black

❒ Hispanic

❒ Caucasian

Membership Requirement: State or Country in which I am currently licensed to practice __________________________

Next Renewal Date ______________________

* In signing this application, I certify that the above information is correct. I understand that misrepresentation or omission of facts is cause for application rejection or future dismissal

Signature of Applicant __________________________________________________________________Date _______________________ Charge $280 to my credit card: ❒ Visa

❒ MasterCard

❒ Discover

❒ American Express

❒ Check enclosed (payable to ACPE)

Credit Card # ___________________________________________________________________Exp. Date ________________________ Signature for credit card _________________________________________________________Date _____________________ American College of Physician Executives 400 North Ashley Drive • Suite 400 • Tampa, Florida 33602 • 800-562-8088 • 813-287-2000 • FAX 813-287-8993

ACPE.ORG

Chart Your ACPE Course • March – December 2009 Consult this course outline to choose the best dates, locations and formats to fit your needs:

Live Conferences 2009 Summer Introducing the Executive PIM! ACPE.org/ExecutivePIM

The Physician in Management Seminar Executive Model July 31 – August 2, 2009 The Ritz-Carlton, Laguna Niguel – Dana Point, California The American College of Physician Executives knows it’s sometimes difficult to get away for five days to complete a course. That’s why ACPE is introducing the Executive PIM — same great content, convenient new format.

Take these four modules live, over the weekend:

Fall Institute ACPE.org/Fall

November 14–19, 2009 – Tucson, Arizona • NEW! Follow the Leader: Coaching and Mentoring a High Performing Team November 14–15 • MetaLeadership: November 14–15 • Essentials of Health Law: November 14–15 • Solve This! Breakthrough Thinking: November 14–15 & November 16–17 • On the Frontline: Leadership for Dept Heads: November 14–16 • Milestone: November 14–16 • Physician in Management: November 15–19

• Marketing and Strategic Planning

• Crucial Confrontations: November 16–17

• Management Skills for Physician Executives

• Science of High Reliability: November 16-17

• Valuable Communication Skills

• ACPE’s Keystone: November 16–18

• Powerful Negotiation Skills

• Managing Physician Performance: November 16–19 • Three Faces of November 16–19 September 18Quality: – October 29

Take these two modules home and complete the course at your convenience: • Finance in Health Care Organizations • Increasing Your Influence

InterAct Distance Education ACPE.org/InterAct • Physicians & Hospitals: Techniques to Optimize: November 18 • Ethical Challenges June 5–25 August 14–September 3 October 2–22 • Financial Decision Making April 17–May 28 June 19–July 30 September 4–October 15 October 30–December 10

Please visit ACPE.org/Education or call 800/562-8088 for more information.

• Health Law April 24–May 14 July 24–August 13 October 23–November 12 • Managing Physician Performance March 20–April 30 June 26–August 6 September 11–October 22 December 11–January 21 • Three Faces of Quality May 8 – June 18 July 24 – September 3

Save the date…

Winter Institute — January 22–27, 2010

• Naples, Florida

“

Getting Fellowship in the ACPE validates my career and my career progression.

“Fellowship allows me to not only give back to the ACPE, it validates me as a physician executive who has helped advance the field of medical management.” “It’s provided instant recognition in the marketplace for my credentials as a physician executive.” — Thomas George Lundquist MD, MMM, CPE, FACPE

Vice President & Chief Medical Officer Wexford Health Sources, Pittsburgh, PA

ACPE Fellow since February, 2008

Fellowship with ACPE A Fellow of ACPE is a Certified Physician Executive and Diplomate of ACPE who has held membership for at least two consecutive years and made a significant contribution to medical management. To be considered as a 2009 candidate for Fellowship, complete your application by February 1st.

To explore further or to request a Fellowship application, call 800-562-8088 or visit www.acpe.org/fellowship

American College of Physician Executives

”

Upcoming 2009/2010 ACPE Live Programs • Mark Your Calendar! at

orm nd F

California ke

ee W w e

Physician in Management Seminar • July 31-August 2 The Ritz-Carlton, Laguna Niguel • Dana Point, California Register Today at ACPE.org/ExecutivePIM

NEW! Follow the Leader: Coaching and Mentoring a High Performing Team MetaLeadership: Removing Barriers & Building Bridges Solve This! Breakthrough Thinking for Physician Executives On the Frontline: Leadership for Department Heads Milestone Physician in Management Seminar Crucial Confrontations in Medical Management NEW! Science of High Reliability ACPE’s Keystone: the Blueprint for High Performance Managing Physician Performance Three Faces of Quality 2009 Fall Institute • November 14-19 Physicians and Hospitals Westin La Paloma • Tucson, Arizona Essentials of Health Law Register Today at ACPE.org/Fall

Tucson

Naples

2010 Winter Institute • January 22-27 Naples Grand Beach Resort • Naples, Florida

Courses NEW! Advanced Health Law NEW! Applications of the Science of High Reliability Leadership Skills for Medical Staff Officers Physician in Management Seminar Three Faces of Quality Advanced Applications in Quality Management Financial Decision Making Conflict and Cooperation: Influence in Organizations

American College of Physician Executives • Inspiring physician leaders—Improving health