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Collaborative Culture

Just returned from The Healthcare Roundtable for Employed Physician Networks where we discussed what happens when physicians transition from independent private practice to more integrated healthcare delivery systems.  I was struck by the number of people who spoke of the difficulty of coming to a common culture.  In a recent article, Dr. Michael Perry, CEO of Freeport Health Network, llinois, wrote that physician employment does not yield ownership:

Ninety-five percent of our physicians are employed by or contracted with the system…. The high percentage of physicians employed by the system by no means indicates that our physicians are any closer to achieving consensus with administration, and we must be intentional about aligning our organizational goals with those of the doctors. The same skills of communication, aligning strategies and goals, and decision making are needed in our situation as are needed in organizations with fewer employed physicians (“A Local Solution for Hospital-Physician Partnerships. 2007. Frontiers of Health Services Management. 24(1):31).

I was not surprised by the difficulty of establishing a common physician-hospital culture, because I was part of the problem at most settings where I have worked.  Physicians are like university professors, whose primary allegiance is to their subject matter (first), colleagues (second), and workplace (a distant third).  I am not sure why, but I suspect that it relates to the amount of time, training, and effort required to learn, practice, and refine a craft.  Where one works is secondary, unless one has strong personal or family ties to a geographic area.  That may not make us seem like team players, even though we do form relationships with members of our operating room teams.

To be provocative and stimulate discussion, let me entertain a second hypothesis, that I call the paradox of culture.  As I mentioned in my book, Collaborate for Success! (p. xiv), culture encompasses the beliefs, habits, attitudes, and assumptions that an organization uses to cope with problems.  Executives make time to shape organizational culture because a strong culture allows leaders to delegate tasks and become more productive.

However, most physicians enjoy bottom-up processes more than top-down edicts.  They have told me that they much prefer being inspired to being supervised.  The only way that I know to develop a common culture is to allow physicians to play a role in shaping it.  In Collaborative Champions, I wrote that physicians can become hospital advocates if they feel that, as physicians, people are listening to them and that they are making their time count.  An abrasive physician from California who had been part of a medical advisory panel (MAP), that helped to set clinical priorities for the next three years, wrote:

I enjoyed the data-driven presentations, in which physicians from all major clinical areas discussed strengths, weaknesses, opportunities, and threats that they faced and proposed recommendations to improve care and to enhance physician-physician and physician-hospital communication. In addition, the MAP heard from the hospital CEO, Directors of Nursing and Finance, and the Chief Information Officer and obtained a perspective of the hospital and the complexity of its operations that we never had before.

Our report, presented to the Hospital Board of Directors, represented the first time that the hospital received a consensus report from practicing physicians. Before, the process involved squeaky wheels pursuing individual agendas.

We evolved from a self-interested view of what the hospital should do for us as physicians to a more empowered view of how the hospital could employ limited resources to improve care for our community. Through the process of discovery, we began to think and act more as long-term partners and co-owners than short-term customers and renters. The Medical Advisory Panel process allowed us to evolve beyond maintaining a level playing field for all physicians to leveraging hospital resources to meet community needs. That clinicians who prided themselves on patient care could come to consensus on long-term priorities gave the Board and hospital administration the confidence to accept their recommendations.

Although it may seem counter-intuitive, physicians can come to a common cultural understanding through healthy competition:

• Primary care physicians at a hospital in Maine achieved 100% compliance with core measures for diabetic outpatients within three months of posting each physician’s name on a paper boat in the waiting room that moved across the wall in a race toward the finish line as each of his or her patients’  results were obtained for fundoscopic and foot lesions, urinary protein, and Hemoglobin A1c
• As I wrote in Collaborative Competition, cardiologists at a Connecticut hospital reduced variation in  procedure times and outcomes for their six-person group to within one standard deviation, decreased their vendors to two, and cut costs substantially, while improving clinical outcomes, in just four months . One of the cardiologists explained, “None of us wanted to be an outlier, except on the positive side.”
• In my 7th ezine, A Creative Way to Engage Physicians, I mentioned that Dr. Bender, the President of the Medical Staff at Cedars Sinai Medical Center, was frustrated with physician hand-washing compliance. So, infection-control staff who caught physicians washing their hands gave physicians $10 Starbucks cards, which increased compliance from 65% to 80%.  However, Dr. Bender wanted to get the rate higher, so he arranged for the hospital epidemiologist to culture physicians’ hands at a medical staff meeting, photograph the bacteria on the Petri dishes, and turn the photograph into a screen saver on every computer in the hospital that physicians used to obtain clinical information. That graphic depiction of bacteria increased physician hand-washing compliance from 80% to nearly 100%, where it has remained for several years.
  Dr. Bender noted, “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior. But when you present them with good data, they change their behavior very rapidly.”

What do you think?

• Do physicians at your hospital resist top-down cultural assimilation
• Have you tried any bottom-up (grassroots) efforts, in which physicians played an active role from the beginning
• What has worked in your organizations to build a common culture

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

Posted in Physician Engagement

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