Published in the June 2015 issue of Today’s Hospitalist
AS HOSPITALIST GROUPS GROW, their governance needs to keep pace. Where once an entire program could gather around a small table and hash out issues, that’s no longer the case for larger groups.
“It is very, very hard to make decisions in a group of 40 people,” says Martin Austin, MD, director of the employed hospitalist program at Gwinnett Medical Center in Lawrenceville, Ga., outside Atlanta.
Dr. Austin should know. As program director for 16 years, he remembers when the group was small enough to be a participating democracy. Group meetings gave everyone a chance to sound off and vote, and he and his associate director laid out agenda items and options in long group e-mails.
But once the group grew to 20 or 25 physicians, meetings began running too long and became unwieldy. The program now has 40 doctors, some of whom are half-timers.
The fix, begun four years ago, was to become what Dr. Austin calls “a republic,” having the group elect five hospitalists to serve two years as members of what became known as the governance council. The council brought issues from group members to the attention of the two directors; it also made recommendations on issues facing the program to the group at large.
The model proved to be very successful “until recently. “If you’d asked me a month ago, I would have said the group runs itself,” says Dr. Austin. Now, however, he and his co-director realize that perhaps the council in its present form may be more of a filter between the directors and group members than the program needs. The search is on to figure out how to maintain the council while steering the group back to more of a one-doctor-one-vote system.
“We need to tweak the system to figure out the best way to communicate and make decisions,” he says. “We had version 1.1, which was a winner, but we may need version 1.2.”
Council evolution
When it was first convened, the council’s role was very amorphous. Set up to problem-solve for the group as a whole, the council initially got together with the directors to talk program issues over.
But eventually, council members wanted to occasionally meet without the directors and to take some decision-making role.
Dr. Austin supported that idea. “We left many issues up to the council to decide like scheduling or the number of patients that doctors on different shifts were expected to see,” he explains. “They would report those decisions at group meetings or make suggestions to the group.”
Only rarely, Dr. Austin says, did the directors have to overrule a council decision. Council members also advised the directors about issues being raised within the program.
That, he explains, was one of the council’s key strengths: giving group members a chance to speak to someone who had no administrative role.
“I’m always surprised that there are issues some members don’t feel comfortable discussing with me,” he says. “It’s a minority, but once you have some sort of administrative link, some people feel they may be perceived as trouble-makers if they raise an issue.” Council members, on the other hand, were seen as “being completely one of them.”
Another advantage: giving a small group the ability to make some decisions. Yet, at times, says Dr. Austin some information from the medical directors wasn’t communicated entirely accurately due to the inevitable confusion resulting from the additional “step” between the directors and the group members.
Big issues to vote on
With the council acting as communication intermediary, Dr. Austin began to worry that leadership wasn’t staying informed as well. “My co-director and I began meeting with large subgroups of program members, and that was an eye-opener,” he says. “While the group has very positive things to say about the council, there were many issues raised that we hadn’t heard of.”
That’s particularly concerning, he adds, because the hospitalists are facing big issues that they need to know about and weigh in on.
The hospital is hiring its first intensivists, for instance, and engaging in and expanding graduate medical education for the first time. “There are a lot of changes,” Dr. Austin says, “which means a lot of chances for miscommunication that result in people feeling a loss of autonomy.”
Part of the fix, he believes, is returning to more direct communication and more group-wide votes on issues via group meetings. But meetings will need to become much more focused than in the past.
Before, Dr. Austin notes, group meetings used to serve as the forum to introduce a new case manager, offer some CME or pack the agenda with eight or 10 items. Instead, meetings would have to be devoted to many fewer topics to be manageable with such a large group “and group members themselves should decide those agenda items ahead of time through online polls.
“We can’t always anticipate what’s going to be the hot-button issue,” he points out. At one recent meeting, he thought a salary item would generate a lot of discussion. But group members readily agreed and moved on to a topic that Dr. Austin considered less controversial: the hospital’s new policy on age cutoffs for hospitalist patients. The hospital medical staff wanted to change the delineation of medical staff privileges from 16 to 15 years old to provide uniform services to younger patients being admitted by surgical service lines, particularly trauma surgery.
Instead, “there was a tremendous debate, and people had diametrically opposed opinions,” he says. “We hadn’t left enough time to discuss it.” (The administration is now reconsidering that new policy.)
A more formal framework
As for the council, some changes may also be in store. It’s time, says Dr. Austin, to work out a more formal framework for the council’s role, determining which practice areas council members should vote on, which they should advise on and which issues need to be voted on by the entire group.
The group also has to decide how the council will function in terms of program communication. “Should members just raise issues in group meetings again, or should the council still act as a go-between between the group and the directors?” he asks. “I suspect what will work is a hybrid of the two.”
Because the group has grown by about 50% in the past four years, the governance council is also being expanded from five to seven elected members. Special consideration will be given to recruiting nocturnists and female group members who have been underrepresented in the past.
Dr. Austin thinks the council still has a vital role in ruling on issues like scheduling and in allowing members to raise issues they may not feel comfortable airing before the whole group. “But we feel we really need more direct communication with the group, polling their opinions and getting their votes,” says Dr. Austin.
“It’s a process issue, and we need to figure out the right process for the group.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
