Published in the October 2016 issue of Today’s Hospitalist
BRIAN FRENCH, MD, MS, knows all about the pitfalls of not having a clear governance structure within a hospitalist group. For many years after several groups merged to create the Abbott Northwestern Hospitalist Service at Minneapolis’ largest private hospital, “there was always a leadership team,” says Dr. French. “But it was not always clear to partners how decisions were made.”
As the group grew to almost 70 physicians, it became clear that it needed more transparent decision-making and more structured governance. In 2014, the hospitalists experienced what Dr. French calls their “Philadelphia moment,” the point where they decided to create a group constitution and figure out how they wanted to govern themselves.
A work group of hospitalists with varied opinions who represented all segments of the program met over several months to map out a new governing charter. (See “Democracies are great, but …“) Per Dr. French, those efforts “resulted in a well-structured executive cabinet with clearly delineated roles and decision-making capability.” Those changes, he adds, have “ultimately improved hospitalist engagement, cohesiveness and group functioning.”
“The two biggest mistakes are giving group members too much choice or not enough structure.”
~ Dean Dalili, MD, MHCM, Schumacher Clinical Partners
Smaller hospitalist programs can sit down and decide group issues with a show of hands. But as groups become larger and more complex, even stellar leaders are overwhelmed with too many decisions. Rank-and-file hospitalists resent not being able to voice their concerns, and poor governance leads to group negativity and an inability to move forward.
But how big should a governing body be, and should groups retain one-clinician-one-vote? We talked with several groups to find out what governing mechanisms they’ve put in place and why those work.
Why good leaders are important
Even small groups (as hospitalists know well) can fall prey to governance problems.
Dean Dalili, MD, MHCM, heads up a 12-physician practice at Wuesthoff Medical Center in Rockledge, Fla. But as senior vice president of medical affairs for Schumacher Clinical Partners, a national practice management company, he also oversees about 30 different programs across the country. Most consist of six physicians or fewer, Dr. Dalili points out.
Such small groups, he notes, are made or broken by the right or wrong leader.
“The two biggest mistakes are giving group members too much choice or not enough structure,” he says. When leaders don’t structure options, hospitalists may settle on solutions that ignore the needs of, say, the ED or case management.
“We’re not administration, so doctors find it easier to approach us.”
~ Susmita Paladugu, MD
Reading Hospital
“Leaders have to frame up choices that meet the needs of the system,” he says. But leading through only direct edict is also a mistake.
“If we can give people choices, that gives them a sense of autonomy, even if they don’t have financial ownership,” Dr. Dalili points out. “The more input people have, the more engaged and committed they’ll be.”
Hospitalist consultant Martin Buser, MPH, notes that when groups grow beyond 10 clinicians, “they have to start morphing from just a gathering of professionals into a business.” That includes devising more sophisticated ways to delegate decision-making and gain member input, says Mr. Buser, a founding partner of Hospitalist Management Resources LLC, a national hospitalist consulting firm.
Only rarely will the original founder of a group “stay effective when there are 30 or 40 doctors,” he says. “The smart ones adapt so they at least create management succession.”
But when group governance doesn’t keep pace with size, consultants are often called in to mediate. “Group leaders can be too close when governance needs to change, and it starts getting personal,” says Mr. Buser. “But group members have legitimate concerns.” Without an effective mechanism for that input, “you end up with a gulf of mistrust where program directors are almost seen as the enemy.”
Giving group members a voice
At Reading Hospital in West Reading, Pa., the hospitalist group last year created a forum for rank-and-file members to air concerns: a steering committee of nine hospitalists.
“When group members themselves latch on to a solution, you get much more buy-in.”
~Thea Dalfino, MD
St. Peter’s Hospital
The driving force behind launching that committee was the group’s size, says hospitalist and committee member Susmita Paladugu, MD: In addition to 10 NPs, the group has 65 physicians. That made it hard for group directors to receive input from the front line, and for group members to know what decisions were being made and why.
The steering committee, Dr. Paladugu makes clear, is “a discussion forum, not a decision-making forum.” Decisions are still made by the group’s medical director and administrator.
But the steering committee allows group members to bring concerns forward. “We’re not administration, so doctors find it easier to approach us,” she notes. Issues raised—often about scheduling or workflow—remain anonymous, with the committee sending its recommendations to the director, who is “definitely” now hearing about many more member concerns.
Committee members also explain administrative decisions to the group. One tweak made since the committee’s inception was assigning five or six individual hospitalists to each committee member.
“Now when the administration passes a new policy, I talk personally to each of my assigned hospitalists about it,” says Dr. Paladugu, who either meets with those doctors face to face or gives them a call.
Another recent change: Committee members will serve only two or three years, not open-ended terms. “People were asking, ‘Why are you on the committee, and I’m not?’ ” she says. “We were picked randomly among those interested, but now the idea is to rotate.”
A core group of team leaders
When hospitalist department chief Thea Dalfino, MD, decided in 2011 to appoint five physicians as team leaders to help her manage the hospitalist group at St. Peter’s Hospital in Albany, N.Y., she expected them to serve one year. But “as time has gone on, there is more work for the executive team to do and more ways for team members to work autonomously,” Dr. Dalfino says.
“We generally don’t have people phone in. It’s very hard to be engaged in a meeting remotely.”
~ Melanie Lee, MD
John Muir Medical Group
The hospitalist program at St. Peter’s has grown from six doctors to 33.5 physician FTEs and 12.5 PA/NP FTEs. By 2011, she adds, the group had not only gotten bigger but much more complex. “We were doing peer evaluations, quality improvement and documentation reviews.”
One team leader heads up billing and coding, another takes charge of patient experience, two head up quality, and one—a PA—represents the NPs/PAs. All executive team members mentor new providers, and all receive 10% FTE dedicated administrative time and a $10,000 yearly stipend.
Meeting with Dr. Dalfino once or twice a month, the team helps set yearly goals and air group concerns.
“The meetings give us the opportunity to solidify our message,” she points out. “How are we going to address an issue and get buy-in?” That united front helps “guide decisions,” she notes, when those issues are presented to the entire group at monthly business meetings. “Team leaders put a positive spin on things so it doesn’t turn into a griping session, and we can move the dialogue forward.”
Sometimes, physicians who haven’t attended a business meeting let her know they object to a decision. “I say, ‘I understand, but I didn’t make that decision. Your colleagues did, so go talk to them.’ “Because of that executive guidance, “we often don’t need to take a vote,” says Dr. Dalfino, although the entire group does vote on issues if there’s substantial disagreement. “When group members themselves latch on to a solution, you get much more buy-in.”
Ensuring a variety of viewpoints
The hospitalist program within the John Muir Medical Group in northern California is even larger: nearly 90 clinicians, including a pool of internal locums. The group now provides 24/7 coverage at three East Bay hospitals.
“Transparency is something you have to do little by little to get people used to it.”
~ Thomas Frederickson, MD
CHI Health
As their numbers grew, “we were never able to reach consensus, and nothing really got done,” says Melanie Lee, MD, one of the group’s co-medical directors. The solution was to establish what has now evolved into a 15-member hospitalist committee.
That committee, says Dr. Lee, makes all the group’s major decisions. Occasionally, the entire group votes on an issue, such as how to structure incentives for working weekends. But that type of decision-making, she explains, is more the exception than the rule. “The committee does a good job analyzing the different permutations of a situation, and we have a good mix of people,” she explains. Group members who object to decisions are welcome to present their view to the committee.
The key to successful representation, she adds, is having a variety of viewpoints. The committee consists of the group’s president and vice president, two co-medical directors, three associate medical directors, four site leads and four group members at large. The committee takes pains to include a wide range of physicians including nocturnists, doctors of different ages and different experiences, and those who want to work a lot of shifts and those who don’t.
Site leads, says Dr. Lee, are “the first-line doctors for hospitalists to raise problems.” General group meetings are held one evening every two months for two hours and are also an opportunity, she points out, for “people to voice opinions.”
As for the committee, it meets once a month over a catered lunch. And “we generally don’t have people phone in,” Dr. Lee notes. “It’s very hard to be engaged in a meeting remotely.”
Challenges with multiple sites
When Thomas Frederickson, MD, was brought in as hospitalist director of Omaha’s Alegent Creighton Clinic in 2011, one of his first moves was to create a governance structure where there had been none before. Within a few years, the hospitalists became part of CHI Health and had programs in six Omaha hospitals.
“Excellence teams leverage the talent of these smart, highly educated people who want to contribute.”
~ Thomas McIlraith, MD
Mercy Medical Group
Each program’s site lead became part of the group’s operations team, along with Dr. Frederickson and the group’s operational lead.As with Dr. Lee’s group, that central council makes all group decisions, although all group members are welcome to sit in on the operations team meetings, which take place every two weeks. In addition (again, true for Dr. Lee’s group), team meeting minutes are e-mailed to all group members.
“The decision-making process is very transparent,” Dr. Frederickson points out. “Transparency is something you have to do little by little to get people used to it.” Individual hospitalists provide input at site meetings, which he and his operational lead attend each month, through their site leaders.
But the governing structure is undergoing what Dr. Frederickson says are “short-term challenges.” This year, the hospitalist group expanded to include two programs located outside of Omaha, with another start-up program planned for next year. That’s brought the group’s total number of clinicians to 80.
One new site is 150 miles away, Dr. Frederickson points out. “We’re used to operationalizing programs in the same market, with the same comp plan and EHR,” he explains. While the new sites are part of CHI Health, “they have a different employer and reporting structure, and they won’t have CPOE for another year and a half.”
In terms of governance, both new site leads take part (via phone) in the operations team’s meeting. But according to Dr. Frederickson, the team now tries to include not just “Omaha-centric items on the agenda,” he says. “Or we may put those items at the end of the meeting, so the site leads outside Omaha don’t have to stay on the line.”
“We realized we couldn’t afford to have decisions made by group consensus.”
~ Brian French, MD, MS
Abbott Northwestern Hospital
He says it’s a new reality that the group is still sorting through. The expanded operations team has common problems to work on across all sites, such as how to better engage mid-career hospitalists.
But “the goal when I first came here was uniformity,” Dr. Frederickson notes. “That can’t be our goal now, yet.”
Expanding grassroots input
In Sacramento, Mercy Medical Group has 80 hospitalists. While those physicians cover four hospitals, “we’ve been very lucky among people heading up multiple sites,” says Thomas McIlraith, MD, who just completed his second term as chair of the hospital medicine department and is the immediate past chair. “The longest commute to any of our facilities is 45 minutes.”
The hospitals are, however, diverse, with two large tertiary facilities and two much smaller community hospitals. Several years ago, Dr. McIlraith launched what he calls a “fairly conventional” central leadership team, consisting of the department chair and the four site leads.
But in 2013, the governance structure expanded to create another layer of grassroots input and decision-making: Each site established its own “excellence team” of five or six physicians (chosen by site leaders from interested doctors) who “decide what issues that individual group is facing and how to tackle them.”
The only requirement for team-proposed solutions: “Teams have to set SMART goals: specific, measurable, achievable, relevant and timely,” Dr. McIlraith says. With the excellence teams in place, each site becomes its own laboratory to test specific approaches. Successful solutions are brought to the leadership team to decide if those can or should be implemented across all sites.
Each excellence team member has one vote, and teams use what Dr. McIlraith calls a “fist-to-five” voting format: a fist means completely opposed, while five fingers is completely for.
“If anybody on the team votes two or below, the action does not move forward until there’s further discussion and the issue is resolved,” he says. As a governing body, he adds, excellence teams are much more structured than the leadership team above them.
“Actually, the leadership team doesn’t vote that much,” says Dr. McIlraith. “The governance of the leadership team is a lot less formal.”
In addition to promoting site representation, the excellence teams enable the group to “leverage the talent of these smart, highly educated people who want to contribute,” he adds. “They not only have a voice, but they come up with solutions the leadership team may never even think of.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
“Democracies are great, but … “
WHEN A WORK GROUP within the Abbott Northwestern Hospitalist Service in Minneapolis set out to create a governing structure for its 60-plus members, it started by tackling some fundamental questions.
How big of an executive council did the group want? And how should decisions be made?
“Democracies are great, but we realized we couldn’t afford to have decisions made by group consensus,” says Brian French, MD, MS, the program’s lead physician who took part in that planning process. “We needed a relatively small group who were trusted by their colleagues to make decisions.”
The work group decided to go with a seven-member executive cabinet, which included the lead physician, the associate lead and the med-peds leader.
“The rest of the cabinet is made up of functions,” Dr. French explains. Executive members—all physicians—also include a business director, a clinical director, a medical education director and a human resources director.
The hospitalist lead divides his or her clinical and administrative time 50/50, while the associate lead has 25% dedicated administrative time and the rest have 10% administrative time, with corresponding compensation. All cabinet positions are elected for two years except the lead, who’s elected for three—although there are no term limits.
Half the committee positions come up for election each year, with group members voting in October and electees announced Nov. 1. None of the positions, including the lead and business director, requires extra qualifications “other than being a physician.” Interested candidates send a letter and their CV to the executive cabinet to get on the ballot, and elections are managed by a nonphysician administrator. Election margins (if more than one person is running for a slot) aren’t publicly announced.
In addition, all group members must serve on at least two committees, either hospital-wide ones or one of the more than one dozen hospitalist-group committees.
“Issues percolate up through those committees to the appropriate director and then the executive cabinet, which votes on which direction to go,” says Dr. French. In addition to giving group members a forum to express opinions, the committee-work requirement offers another benefit: “People realize that making decisions is not easy, and they become privy to the wranglings that go into a seemingly simple decision.”
The executive cabinet does use the full group’s monthly meetings to decide how to operationalize some of the decisions it makes. The cabinet recently voted, for instance, to create a backup call system at night.
“We made that strategic decision, but we didn’t really care if call was assigned for a week at a time or only a day,” says Dr. French. “We’ll frequently ask the group to guide us as to how they want such a decision implemented.”
