As chief quality officer for Allegheny Health Network, Brian M. Parker, MD, is responsible for ensuring that the highest standards of patient care quality, safety, and service excellence are achieved.
This article was co-wrote by Brian M. Parker, MD, and Vibhas Ratanjee. Ratanjee is a senior practice expert with Gallup, based in Gallup's Irvine, California office.
Health care has been enduring significant change and costly disruption, which has been further exacerbated by the COVID-19 pandemic. This ongoing industry-wide transformation requires considerably different qualities of leadership than those of previous eras.
One possible answer is to hire more administrators, financial controllers, or business executives, or engage outside consultants. Indeed, the number of administrators grew 3,200% percent in 35 years. Another is to introduce a new generation of physicians into hospital and health care system leadership roles. Physicians have first-person understanding of the challenges and opportunities of delivering health care. Putting them front and center of the patient experience incorporates their unique perspective into decisions that drive important patient outcomes.
It is also good for business. A U.S. News & World Report study of the top 100 best hospitals revealed that hospital quality scores are approximately 25% higher in physician-run hospitals than in administrator-run hospitals. Another research study showed that physician-led hospital systems had higher quality ratings across 12 medical specialties.
This does not mean that hospitals can be only run effectively by physician leaders -- there are many excellent dyad partnerships between physicians and administrators and there are excellent administrators who don’t have a clinical background – but it does mean physician-leaders offer a uniquely valuable perspective on hospital administration.
However, effective leadership requires knowledge and experiences that vastly exceeds the health care economics classes, management workshops, etc. physicians receive in medical schools, residencies, or fellowships. Physician leaders need financial expertise coupled with a growth and performance optimization focus. They must know how to successfully manage stakeholders and navigate increasingly ‘matrix-driven’ hospital and health system organizational structures. Lastly, the focus on the quadruple aim in health care (population health, patient experience, reducing cost, and clinician / care team wellbeing) requires a specialized mindset and precise developmental experiences – all with 1 eye on present and the other on the future.
Physicians need early “crucible” experiences
Insufficient leadership education is a detriment to hospitals and physicians. A 2015 review of physician leadership development programs published in the Journal of General Internal Medicine highlighted significant gaps including limited use of interactive learning and feedback to help physician leaders develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes. As a result, physician leaders’ base of knowledge and experience is too often ex post facto, which is when it’s least useful.
Without the depth and rigor of proper experiential leadership training – the kind that business leaders receive routinely -- physicians who want leadership roles often become autodidacts of leadership: consuming business books, management publications, and sometimes even formal course work. This takes a great deal of time and effort, and is inadequate instruction for leadership in the health care setting.
Physicians need real leadership experiences early on in their careers. These crucible events grant learning, growth, and increased capacity to lead effectively, resetting how physicians view their work, their impact on others, and their lives. In the absence of these opportunities, physician leaders must always learn how to lead by leading, obtaining knowledge just after it has the chance to benefit them or their organization. And while experience is consistently shown to be a better leadership skills lab than classroom training, ex post facto learning comes too late for optimal decision making in a physician's career.
The leadership experiences physicians need most
In an increasingly uncertain health care environment, leaders need exposure to real challenges to test their mettle in real business situations. It is almost impossible to manufacture those experiences, but it is possible to position physicians to receive them organically and – importantly – coincident with each stage of a leader’s development.
To determine the ideal chronology and content of those experiences, Allegheny Health Network (AHN), as part of Highmark Health, recently collaborated with Gallup to ascertain and codify the critical key experiences that physicians need to become successful leaders. The research included in-depth conversations with 43 physicians, the majority from AHN, as well as successful physician leaders from 7 other health care systems. Each of these interviews lasted for approximately 45 minutes to an hour. After the interviews were completed, the AHN and Gallup teams also conducted several levels of content analysis, iteration and validation before the key experiences were confirmed.
This research made it clear that 6 discrete key experiences are essential.
Every physician leader stated that early, active involvement and leadership in administrative committees is an essential key leadership experience.
Committee experiences provide an essential mindset shift. Their involvement moves physicians’ focus from the individual to a '30,000 foot' view of the hospital, and teaches critical problem-solving skills related explicitly to non-clinical areas that can have a significant impact on care delivery. And participation teaches physicians that genuine team-based care and organizational solutions come from the collective intelligence and experience of the individual committee members.
However, note that superficial committee work or passive attendance easily wastes physicians’ limited time. Committees need to have specific mandates, defined work with measurable impact and, importantly, clear learning goals. Many physicians stated they also benefited from spending more time observing, emulating, and seeking advice from others, including senior physician leaders who could be trusted role models.
Hospital management systems are traditionally 'command and control' structures in which physicians are expected to know most if not all the answers.
But today's hospital structure is complex, matrix-driven, incorporates multiple lines of reporting – and can easily overwhelm physicians. It might even inadvertently drive some to operate with a silo mentality with minimal awareness of the broader organization. This study made it clear that physicians aspiring to leadership positions must intentionally involve themselves in a multidisciplinary, cross-functional project team aimed at important organizational initiatives, opportunities, or turnarounds. These projects help physician leaders gain an authentic understanding of stakeholders’ interests, opinions, and sometimes competing views. This enables them to communicate a strong vision and influential rationale for change – and an understanding that siloes prevent real change – while helping them adapt to the dynamic health care environment and thrive in the face of continuous disruptions. It also underscores the importance of building emotional intelligence in leadership development practices.
Hospitals can provide these experiences rather easily, but it must be done purposefully and at the right time in a physician’s career. Developing leaders can be given assignments with significant financial consequences, visibility, and exposure to executive leadership. They can take responsibility for a post-merger integration or revitalizing a failing unit, division, or program. Whatever the project, it must pull representatives from various functions, facilities, specialties, and roles across the hospital or system and unify them around the mission of the transformative initiative.
Physicians must learn to lead through influence rather than just authority. It’s a necessary component of effectiveness in a complex work environment in which rapport with other leaders is essential.
Physicians aspiring to be leaders would do well to gain the ability to productively communicate with – not talk at -- multiple stakeholders on non-clinical issues, both internally and externally. They need to become adept at meeting their objectives by cutting through politics and power equations through diplomacy and negotiation.
Those who do build a network of supporters -- which might not come naturally to all physicians – can help to broaden the physician leaders’ influence and provide indispensable support. Physicians can build this network by participating in internal activities alongside key stakeholders such as the hospital president and other C-suite leadership, and via external opportunities like medical societies and conferences. These activities provide a 'system wide' view of the health care ecosystem, and engaging with payers, managed care organizations, and other external professionals offer a vital education in the business side of health care.
Professional networking also opens a view onto other systems, processes, policies, and operational best practices that physicians can use to draft benchmarking standards drawn from other hospitals, health care systems, or out-of-industry exemplars. The pinnacle of this experience is sharing knowledge of cross-functional projects and care transformation initiatives with other physician leaders.
'Out of expertise' skill building
Most physicians, as a rule, dislike spreadsheets and financial administration. In a 2018 survey of more than 3,400 physicians, many said that electronic health records (EHR) and value-based care and reimbursement compromise the traditional doctor-patient relationship. Some research indicates that EHR failure can lead to clinician burnout, low job satisfaction and, according to a Stanford survey, a decline in clinical effectiveness for 1 out of every 2 clinicians.
Nonetheless, physician leaders need to learn the fundamentals of administration. There are numerous activities that enable rapid acquisition of experience, skills, and knowledge outside the scope of that which is taught in medical school or residency: job shadowing different functions/roles and engaging with subject matter experts; leading an assignment, job, or task; joining in strategy development, project management, resource coordination; or participating in budgeting, ROI analysis, and hospital management.
These out-of-expertise skill building opportunities provide a holistic view of functions and programs and help physician leaders develop fundamental leadership capacities – especially in financial literacy. The economics of health care require a thorough knowledge of verbiage, utilization reviews, and business strategies including payer contracts, under-writing, annual strategic planning, annual budgeting, and resource planning.
These experiences build confidence and facilitate a more practical understanding of the technical skills that are pre-requisite for growing into the next leadership level or role. But perhaps more importantly, they help physicians understand administration so they can make effective strategic decisions with a more significant impact on patient outcomes.
The role of a mentor is crucial in developing physician leaders. Good mentors push physicians out of their comfort zone and beyond what they thought they could achieve – which is necessary for authentic growth, reflection, and personal change -- in an environment of familiarity, comfort, respect, and trust. To enable these relationships, hospitals and health care systems must support mentorship programs with clear parameters, well-defined goals, and developmental objectives.
Physicians should have opportunities to shadow other physician leaders during critical activities and tasks, such as strategy formulation, budget planning, etc. Frequent performance feedback and advice from valued role models in specific areas of physician leadership knowledge and mastery are essential. So is advice on managing a difficult situation, a turnaround, or new venture. Though physicians should also proactively seek partnership and learning from external experts and leadership coaches, organizations that formally offer more structured opportunities for them likely reap more from them.
Building a new venture from scratch
As physicians gain fundamental experiences, hospitals and systems must up the ante by introducing more complex and challenging experiences. As leaders gain experience, they’ll develop a more advanced grasp of health care business and thinking– visioning, strategy, resourcing, financing, and operationalizing a new venture – and how to negotiate resources, balance priorities, and obtain buy-in and timely support by effectively engaging key stakeholders and partners.
Our analysis identified an exceptionally useful means of achieving this important key experience: building a brand-new venture. Just pitching the idea to solicit the necessary support and access to critical resources is educational, but the actual practical experience gives physician leaders invaluable perspective. And if carefully engineered, developing a new venture can create expertise in the technological advances that are transforming health care – which the physician leaders of the future need to keenly understand to leverage well.
An experience like this requires patience (unlike some clinical outcomes that physicians are more accustomed to) and resilience in the face of significant challenges. The most beneficial projects – to the physician leader’s development – are those that come with significant challenges in unexplored areas or those that have never yet met with success. Such projects provide opportunities to learn invaluable skills: holistic business management, an understanding and appreciation of each function, knowledge of every role’s contribution to the whole, a thorough understanding of the demands of running a new entity, and the ability to rally enthusiasm and inspiration for a new venture, idea, or opportunity.
Designing pivotal leadership experiences
These research results on key experiences are essential for health care organizations, executives, physician leaders, and physicians who want to be leaders.
Even those physicians who are motivated and incentivized to lead, who know the challenges of health care and have the perspective needed to transform a broken health care system, do not know which experiences they need most. A well-designed physician key experiences program is, therefore, essential. And the starting point is to develop a key experience inventory:
Health care is changing rapidly. And physicians who want to take on key leadership positions would do well to identify the significant leadership experiences that can accelerate their growth. There is some urgency in developing physician leaders for and in the future. One-third of all currently active physicians will be older than 65 in the next decade. We are staring down a physician leader succession crisis.
The next generation of physician leaders will face increasingly complex administrative tasks, will be orchestrating care-team development, and must engage patients and employees in a health care dynamic that is continuously evolving. They will have to adapt to constantly changing technology, manage internal and external stakeholders adeptly, and navigate an organizational structure that demands a holistic understanding of roles and functions across the broader health care ecosystem.
Bridging the gaps between roles, functions, programs, specialties, and hospitals while aligning employees towards common goals will be critical. And the focus on the quadruple aim in health care will require a highly specialized leadership mindset and development experiences – all with an eye towards the future, which likely is radically different than the present.
And there is no one better equipped to do that than a physician leader who has been developed through key experiences to lead. Now is the time to ensure they get the leadership experiences they need to succeed –when they need them, not after the fact.
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