New physician integration models give health system boards and leaders the opportunity to revive and apply the concepts of medical professionalism organizationwide for strategic benefits.
Health system boards of directors and executives are positioning themselves to have a profound effect on medical professionalism in the United States. As market forces continue to draw physicians into health system or accountable care organization alignment, the opportunity for local health systems to define, promote, measure, monitor and reward professional behavior is growing and creating the possibility of revitalizing medical professionalism.
Trustees and C-suite members can seize this opportunity by incorporating the values of medical professionalism into their formal organizational value set, and assuming accountability for advancing medical professionalism in their communities. To do this, leaders should organize and appoint a new system-level multidisciplinary professional standards committee charged with two purposes:
• advancing local medical professionalism
• developing an integrated code of values for all members of the institution
Over time, the investment in such an initiative will accelerate alignment of purpose between clinicians and the organization, leading to better system performance in the emerging value-based, consumer-driven market.
What Is Medical Professionalism?
Physician values and expected behaviors are embodied in the concept of medical professionalism. In 2002, the American Board of Internal Medicine Foundation, American College of Physicians Foundation and the European Federation of Internal Medicine jointly authored “Medical Professionalism in the New Millennium: A Physician Charter,” in response to members’ growing concern about the commercialization of medicine and its corrosive effective on professionalism. Considered the gold standard for defining medical professionalism, the charter has been widely published, translated into 12 languages and endorsed by more than 130 professional organizations and associations.
The charter defines physicians’ professional responsibilities to individual patients and society as a whole in three principles:
• the primacy of patient welfare
• patient autonomy
• social justice
Then, it enumerates the professional responsibilities that inform how physicians can practice those principles in the form of commitments to honesty with patients, scientific knowledge and maintaining trust by managing conflicts of interest.
Despite the charter’s publication in and broad communication through medical journals and associations over the past 12 years, its impact at the grass roots level of the practicing physician has yet to be fully realized. A health system’s board and executives should not assume that all of their system’s employed and affiliated physicians are functioning in compliance with it.
Indeed, when physician attitudes and behaviors are compared against the charter commitments, studies have shown significant shortcomings: poor practice compliance with evidence-based medical guidelines (failure to pursue scientific knowledge), a reluctance to report impaired colleagues (failure to self-regulate), concern over sunshine laws (failure to manage conflicts of interest), and a propensity to hide medical errors (failure to be honest with patients).
It’s not surprising that gaps in professional behavior exist because, in most communities, there are few ongoing programs for promoting the charter and keeping professional values top of mind for busy physicians. Despite publication and near universal support of the ABIM charter, translation of the values and principles to front-line practices has been disappointing.
Window of Opportunity
Community health systems are responding to reform by creating new physician-led governing structures in their medical groups, clinically integrated networks and accountable care organizations to align and engage physicians in delivery system transformation. Such physician-led boards typically are supported by subcommittees focused on quality, finance, contracting, and peer review or credentialing.
Although these new structures are being formed primarily to prepare providers to move to new value-based payment models, there is a great opportunity to supplement clinical integration with value integration through the formation of a system-level professional standards committee. Designing such a committee to be linked to the traditional peer review committee of the employed medical group and credentialing committee of the clinically integrated network or ACO is the first step toward developing system accountability for medical professionalism.
Unlike in professional associations, state medical boards or hospitals, health systems are reorganizing to have all of the levers needed to lead a renewal of medical professionalism in their communities. These include the ability to define, measure, promote, monitor, apply peer pressure and reward medical professionalism. Professional standards committees soon will be in position to influence the professionalism in their local medical communities broadly through employment agreements or network participation agreements — both with professional standards requirements.
Community member participation on the professional standards committee is essential. Health system oversight by a community board of trustees and participation on a professional standards committee can provide an important consumer perspective on what constitutes professionalism in the 21st century and keep the professional standards committee from becoming a physician advocacy body.
Building a Unified Culture
System-level professional standards committees also have the opportunity to lead a process of value integration between practices and the health system. Of four conceptual legs of integration — structural, functional, clinical and cultural — cultural integration is the least addressed or effectively pursued. The cultural divide between practicing physicians and traditional health system leaders is well-known. But with the health system business model moving from managing the physician workshop to effectively and efficiently managing the care delivery process, the opportunity to develop a common set of patient-centered core values for both physicians and the system seems within reach.
For most hospital-based health systems, published institutional values usually are developed and adopted by the board and management and displayed on their websites and in publications. Typically, the values consist of five to six words, including integrity, accountability, service, diversity and respect, all of which can be mapped to the charter’s principles and commitments [see Health System Values Align with Medical Professionalism, Page 27]. As health systems continue to employ or contract with physicians, leaders must ask:
• How do our published values relate to the professional values physicians bring to the organization?
• Are our values sufficiently patient-centered?
• Should we consider adoption of the ABIM charter as our institutional value guide? Do the values apply to clinicians other than physicians? Do they apply to employees?
• Would adoption of the ABIM charter position us to lead advancement of medical professionalism in our community?
Unique Competitive Advantage
Physician behaviors, including team interactions, work habits, patient interactions and treatment recommendations, have an enormous impact on the cost, quality of care delivered and patient satisfaction. We predict that those organizations that make advancing medical professionalism a strategic priority will create a competitive advantage in their market. A highly professional workforce committed to the principles of the ABIM charter will:
• create greater patient trust and loyalty
• deliver safer, higher-quality care
• have less litigation and regulatory risk
• manage resources more efficiently
• practice in a consumer-centric manner
• work as teams in a coordinated manner
Developing a system-level professional standards committee is appropriate for any hospital or health system that has an employed medical group, clinically integrated network or ACO. To get started, include a professional standards committee in the design phase of any clinically integrated network or ACO and link it to the groups responsible for peer review in the medical group and credentialing in those organizations. Then, select a highly respected physician to lead the new committee [see Advancing Medical Professionalism: Five Steps for Boards and System Leaders, Page 26].
In the 1990s, accountability for hospital quality and safety expanded from the medical staff to the hospital boards and executive teams. In 2015, as physicians create new links to health systems through employment or ACO participation, the responsibility for defining and advancing medical professionalism will migrate in a similar manner to their chosen organization. Boards and system leaders need to prepare to embrace this opportunity both for strategic purposes and for the broader community purpose of revitalizing medical professionalism.
Dale P. Anderson, M.D., M.B.A. (firstname.lastname@example.org), is managing director, BDC Advisors, Miami.
Advancing Medical Professionalism: Five Steps for Boards and System Leaders
1 Appoint a system-level professional standards committee:
• Select a physician who embodies medical professionalism to lead the committee.
• Include trustees, community leaders and other clinical staff.
• Link medical group and clinically integrated network or accountable care organization credentialing and peer review to the system professional standards committee.
2 Create a committee charter to advance medical professionalism and integrate values using the American Board of Internal Medicine charter:
• Focus early meetings on committee member education regarding medical professionalism and the ABIM charter (literature review, speakers, etc.).
• Set up a board-level process to explore integrating the ABIM charter with institutional values (use third party to facilitate discussion).
3 Perform a medical professionalism audit of the health system:
• Use a third party to interview and survey physicians about medical professionalism.
• Review existing policies related to professionalism, such as compensation, conduct and conflicts of interest.
• Benchmark the organization’s degree of medical professionalism and identify gaps.
4 Initiate improvement plan:
• Create a professionalism scorecard and establish baseline performance.
• Institute programs for advancing medical professionalism (continuing medical education or online training) using ABIM charter principles and commitments.
• Link professional standards committee activities with national organizations that promote medical professionalism.
5 Recruit for and reward professionalism:
• Embed ABIM charter principles and commitments into employment and CIN or ACO participation agreements.
• Use key behavioral interview questions to probe attitudes and beliefs regarding medical professionalism for potential recruits.
• Reward and recognize individuals who demonstrate outstanding medical professionalism. — D.P.A.