Practice Economics

Business Blueprint


 

Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.

Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?

The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.

“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”

There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”

Start at Self-Assessment

Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.

Dr. Wright

Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.

How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).

Identify Core Leadership Requirements

Dr. Silversin

There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.

Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.

The hospitalist leader is responsible for many tasks, the authors write, including:

  • Blending marketplace needs with those of these various stakeholders;
  • Managing budgets, billing and revenue cycles, resources, and performance metrics; and
  • Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.

Self-Training Resources

Here are a few books that veteran hospitalists have found useful early in their leadership careers:

  • Good to Great: Why Some Companies Make the Leap ... and Others Don’t, by Jim Collins (HarperBusiness, 2001).
  • Switch: How to Change Things When Change Is Hard, by Chip Heath and Dan Heath (Broadway Business, 2010).
  • Getting to Yes: Negotiating Agreement Without Giving In (2nd Edition), by Roger Fisher and William Ury (Penguin, 1991).
  • The 21 Irrefutable Laws of Leadership: Follow Them and People Will Follow You (10th Anniversary Edition), by John C. Maxwell (Thomas Nelson, 2007).
  • Bargaining for Advantage: Negotiation Strategies for Reasonable People (2nd Edition), by G. Richard Shell (Penguin, 2006).
  • The Five Dysfunctions of a Team: A Leadership Fable, by Patrick Lencioni (Jossey-Bass, 2002).
  • Crucial Conversations: Tools for Talking When Stakes are High, by Kerry Patterson (McGraw-Hill, 2002).

These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.

Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”

Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”

Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”

Leadership Self-Assessment

Dr. Klocke

The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).

Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.

A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.

You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.

Pursue the Right Training Venues

Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.

Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).

The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.

A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).

Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.

As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine, the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what HM leaders should be focusing on.—Lakshmi K. Halasyamani, MD, SFHM, vice president, quality and systems improvement, Saint Joseph Mercy Hospital, Ann Arbor, Mich., SHM board member

Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.

Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.

Advanced Training

Dr. Agborbesong

For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.

The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.

An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.

Dr. Stahl

“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.

A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”

Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.

Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.

Dunham

Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.

As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.

“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Reference

  1. Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.

Veteran Advice For Aspiring HM leaders

Dr. Howell

Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate­ long-term relationships.

Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.

Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.

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