Cover Story
Cultivating Trust: The Board-Medical Staff Relationship
By Susan Meyers
At a time when hospital boards of directors are under mounting pressure to demonstrate measurable quality and safety outcomes, many boards are finding that one of their most valuable relationships in pursuing these goals—that with the organized medical staff—is often wrought by growing tension and distrust. An increasingly competitive health care environment coupled with waning physician loyalty, turf battles, declining reimbursement and more stringent Medicare regulations, have contributed to deteriorating relationships between many hospital boards and their medical staffs. Realizing the important role of the medical staff in achieving quality goals and organizational success, boards are beginning to look for ways to restore this partnership and engage physicians in hospital strategy and a quality agenda.
“Physicians are the ones that admit patients to the hospital, and, ultimately, they are responsible for overseeing the care of the patient,” says Jeff Miller, president and CEO of 384-bed High Point Regional Hospital (HPRH) in High Point, N.C. His hospital recently embarked on a multifaceted campaign to ease tensions and cultivate a trusting, more engaged relationship between the medical staff, hospital administrators and the board. “If there is an adversarial relationship, the patient is ultimately the one who is going to suffer, punctuating the need to have a strong, positive relationship with your medical staff,” Miller says.
HPRH’s efforts to rectify its deteriorating physician relationship recently landed it Press Ganey’s annual Success Story recognition after the hospital’s physician satisfaction scores reached an all-time high of 89 percent in 2006, up from a low of 67 percent in 2004. “It’s a very challenging and difficult time in health care for hospitals and physicians,” Miller says. “But we have found that the key to gaining physician trust and support has been transparency, communication and involvement with the medical staff in our governance.”
If hospital leadership wants results, physician engagement is critical, agrees James Reinertsen, M.D., president of the Reinertsen Group, an independent consulting and teaching practice based in Alta, Wyo. “Boards need to stop thinking of doctors as customers and should start thinking of them as partners. Optimal hospital quality will only be achieved when the hearts and minds of the medical staff members are engaged in a common cause for quality with the hospital,” notes Reinertsen in a 2007 Institute for Healthcare Improvement white paper report, “Engaging Physicians in a Shared Quality Agenda.”
To illustrate the magnitude of the physician’s role, Reinertsen suggests hospital leaders look at the patient care process as a product of inputs (i.e., patients, staff, equipment and supplies), processes (i.e., providing care) and outputs (i.e., outcomes, safety events, patient satisfaction, costs of care). The medical staff provides the patients and controls the processes and outputs because everything is derived from the orders written by the physicians. The hospital board provides the other inputs by supporting a budget that supports appropriate equipment, qualified staff and facilities. “A hospital needs solid inputs from administration and reliable processes from the medical staff to achieve quality results,” says Reinertsen. “This requires a very tight partnership.”
The problem that many boards have, explains Reinertsen, is that the typical hospital structure comprises the board, administration and medical staff at each corner of a triangle. The relationship between the administration and board is typically a very managerial relationship, in which there is cordial give and take and clear accountability. However, there is no such “managerial” relationship between the board and medical staff and so the result is often a high-voltage, high-tension, emotionally laden relationship in which the two resort to using “governance weapons,” Reinertsen says. For instance, a board weapon might be: “The board is suspending your privileges.” Likewise, a typical weapon originating from the medical staff might unfold as: “We have taken a vote of no confidence in our administration,” or “I am taking my patients to another hospital unless I get what I want.” Traditional points of contention have focused around profit, with the medical staff believing the board cares only about financial issues rather than clinical issues and the board thinking physicians are only concerned about their own financial wealth.
To break down these misunderstandings and work toward cultivating a better relationship, Reinertsen says, the board needs to learn how to engage their medical staff in more productive conversations. “Boards need to change the nature of their questions,” he says. “They need to start asking probing questions and engaging their medical staff in meaningful conversations. Likewise, the medical staff needs to be able to remove its ‘physician hat’ during a board meeting and act and think as members of the board, not members of their own personal practices.”
Re-establishing hospital/physician alignment should begin by developing a plan that correlates with the quality agenda. Startled by the results of its 2004 Press Ganey survey that revealed physician dissatisfaction in several key areas, HPRH used these results to build a plan for building and sustaining physician engagement. The survey revealed that physicians were unhappy with hospital leadership, responsiveness, communication and strategic planning. Realizing they had a lot of ground to cover, one of the first steps the hospital took was to hire a chief medical officer and corporate compliance officer, Greg Taylor, M.D., charged with increasing communication with the medical staff and developing strategies to improve relationships. Providing easy accessibility to the medical staff, Taylor’s office is located in the medical staff lounge, a prime location where physicians congregate and pass through while coming in and out of the hospital.
“A pivotal part of our physician satisfaction improvement comes from the chief medical officer position we created,” says Susan Culp, HPRH board chair. “Dr. Taylor’s visibility and understanding of common physician concerns helped bridge the gap between administration and the board.” The hospital adopted the Malcolm Baldrige performance evaluation and improvement criteria to help guide its efforts to improve physician relationships. The criteria forced the hospital to ask some hard questions, such as: “How do we communicate with physicians?” “How do we lead?” “How do we develop strategic planning?” and “How do our senior leaders promote vision and values?”
“Working through these questions made us realize that we had a lot of work to do,” Taylor says. “We obviously were not doing as well as we thought. We had to really rethink how we were going to lead the organization.” Led by Taylor, the hospital began a series of initiatives to win back physician trust. To open up lines of communication, Taylor surveyed all physicians about their preferred means of communication. The hospital then developed a series of communication tools to ensure they reached every physician through a combination of e-mails, faxes, newsletters and even CDs.
Using these newly formed communication tools, all physicians now receive a quarterly strategic plan status report of medical staff meetings and medical executive committee meetings. The CEO, chief medical officer and chief nursing officer also record a short summary of these meetings on a CD that includes “next action steps.”
Seeking to further medical staff investment in the hospital’s strategic plan, HPRH expanded physician representation on the board by identifying additional physician leaders and inviting them to become members. Additionally, the board created a Quality and Planning Committee and appointed a physician chair. Board members also were appointed as members of important physician committees such as the Executive Medical Staff Committee.
“The fact that we have four physicians from our medical staff on our board shows how we value their input to ensure we serve our mission of providing exceptional health services to the people of our region,” Culp says. “Success requires everyone’s commitment along with the desire to do what’s best for patients and the High Point community.”
This new level of physician involvement “completely changed the tone of our meetings,” notes Miller. “It really opened up the dialogue. In the past, we spent more time on financial issues, and now we spend more time discussing quality issues because the doctors are right there to provide input and personal experience.” As the physician/board relationship grew more collegial than adversarial, the board and medical staff began finding more ways to collaborate rather than compete, adds Miller.
“Once the questions and discussions began flowing, it was interesting to see the types of questions the board had for the doctors. This included extensive dialogue about issues facing physicians ranging from technical aspects of care, such as how to manage heart attacks, to the pressures of managing a private practice from a business aspect. This dialogue was a valuable reminder to the medical staff that the laypeople they serve are represented at the very highest level of the board,” Taylor says.
Miller says the structural changes were far-reaching across the entire organization. “Their peers began seeking these physicians out to find out what transpired in these meetings,” he explains. “Providing members of our medical staff [with] governance authority—that’s about as powerful a message as you can send out.”
To facilitate greater physician involvement in hospital initiatives, HPRH also rewrote the medical staff bylaws. Now active members of the medical staff can still participate in medical staff meetings even if they don’t admit to the hospital. This was especially beneficial for family practitioners and internists who no longer admit patients to the hospital because hospitalists now provide that service. HPRH also reorganized medical staff department divisions to improve physician participation and to equalize workloads between departments. The new bylaws decreased the number of committees physicians had to serve on as well as the number of meetings they were required to attend and allowed meeting policies to be established by each department.
To further promote physician engagement, members of the Medical Executive Committee are invited to attend the monthly board meetings, and the entire medical staff is invited to attend the annual board of directors planning retreat. “This sends a collegial message to our medical staff that we want you to become involved, and we want to work with you,” Miller says.
To gain greater support and awareness of the quality agenda, HPRH formed a Quality and Planning Committee of the board, which was instrumental in elevating the significance of quality goals within the hospital’s strategic plan and in establishing a common vision, Miller says. “Ultimately, everyone is responsible for quality starting with the board all the way down to the physicians, nursing staff and other allied health professionals,” he says. “But it begins with the board, [which] is responsible for establishing it as a priority and ensuring all the right pieces are in place from the appropriate equipment and facilities to qualified clinical staff and access to hospital resources and services.”
C.J. Boltser, vice president and managing director of Health Care Practices for the Hay Group, a global management consulting firm based in Philadelphia, agrees. “Accountability begins with the CEO and board of directors. They are responsible for setting the tone as to how important these quality initiatives are within the organization,” he says. “There has never been a topic that has brought the medical staff and top leadership closer together in a dialogue than ever before. The very nature of the topic forces management to come to the table with physicians and discuss outcomes.”
To engage the medical staff, Bolster says that the board needs to think the way physicians might think. For instance, since most physicians base their decisions on evidence, processes and outcomes should be presented by physician leaders to the board with supporting data that are understandable and meaningful to both physicians and board members.
Providing management support is critical to keeping physicians engaged and helping them achieve success in reaching quality goals, notes Reinertsen. “Administration needs to act as a partner in making things happens—that means providing both financial and staffing resources,” he says. “For many years, the medical staff has felt like spectators in many hospital activities. They’ve never been asked or given the tools to be held accountable. But given the proper resources, physicians will step up to the plate.”
Tools and processes also need to be in place to correct problems when quality goals are not being met. For instance, HPRH uses scorecards to measure quality indicators. To address areas that fall below quality goals, the hospital employs Six Sigma teams made up of individuals close to the problem to analyze and improve quality processes. Six Sigma is a quality improvement process that uses a data-driven approach and methodology to reduce process variations by eliminating defects and waste.
HPRH has also established a process of accountability for each individual physician. Every six months, physicians receive individual quality and safety reports that summarize data relating to areas such as quality of care provided, staff and patient complaints, length of stay, infection rates and cost of care based on diagnosis. This information is compared with their peers as well as other hospitals and is also reviewed by the peer review committee, a branch of the board’s quality and planning committee. The peer review committee comprises a multidisciplinary group of physicians with the ability to provide expert input when reviewing technical issues. If significant concerns cannot be resolved by the peer review committee, the report is reviewed by the medical executive committee, which will then discuss concerns with Taylor to achieve a resolution.
Miller says HPRH’s efforts to engage physicians in hospital strategy have resulted in benefits throughout the organization. “We are seeing improved physician satisfaction scores, greater physician awareness and interest in organizational goals and quality, a more collaborative working relationship between the board and medical staff, and a better understanding on the board’s part of the types of clinical challenges physicians face daily,” notes Miller. When the board can unite their medical staff in a common cause with the patient as the central focal point of the hospital’s mission, good things will happen, says Reinertsen. Only with this united partnership will the board be successful in building and sustaining a culture focused around quality.
Susan Meyers is a freelance writer based in Omaha, Neb.
This article 1st appeared in the November 2008 issue of Trustee Magazine.
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