Ezines

Ezine, short for electronic magazine, represents brief white papers on topics readers feel are important in the evolving field of physician-hospital relations, including:

Don’t Let Process Issues Bite You: Lead with a Checklist, 6/06
Competition: An Opportunity to Improve Physician-Hospital Collaboration? 8/06
Hot-Button Words to Avoid in Healthcare, 4/07
Keys to Successful Electronic Healthcare Record Implementation, 6/07
Understanding the Relationship Between Primary Care and Hospital Revenue, 10/07
Cutting-Edge Physician Recruitment Strategies, 12/07
A Creative Way to Engage Physicians, 2/08
Engaging Physicians in Improved Marketing Efforts, 4/08
Engaging Physicians in Cutting Expenses, 8/08
Four Keys to Sustainable Collaboration, 10/08
Coming to Your Community Soon? CMS Global Fee Demonstration Grants 11/08

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1) Don’t Let Process Issues Bite You: Lead with a Checklist, 6/06

I never imagined suboptimal healthcare collaboration would happen to me. Twenty-four hours before a group presentation, we were arguing over the format of our presentation rather than putting the final touches on it. We had spent so much time gathering data that we never talked about our expectations for how we would work together.

In medicine, good judgment comes from bad experiences. From then on, I resolved to discuss process issues up front and teach physician colleagues to do the same. We use checklists all the time when doing procedures. Why not use them at the start of meetings or other group projects?

Here is the checklist I use with physicians at the start of meetings and task forces. I find it a helpful starting point for discussion about necessary issues, such as expectations for tactful discussions and maintaining confidentiality of proprietary data:

As team members, we resolve to:

Show up on time for meetings and notify the leader in advance when unable to be present
Actively listen and participate
Openly exchange ideas and viewpoints
Build on one another’s ideas
Refrain from personal criticism
Remain focused on the tasks for which we are responsible
Monitor our progress at regular intervals
Share responsibility for deadlines and ownership of results
Develop win-win solutions
Respect members’ confidentiality

Checklist reprinted with permission from “Surgeon frustration: Contemporary problems, practical solutions.” Contemporary Surgery. 2003;59(2):76-85, Dowden Health Media.

2) Competition: An Opportunity to Improve Physician-Hospital Collaboration? 8/06

In Chapter 3 of my book Better Communication for Better Care, I offered a 3-part strategy for dealing with competition:

1) Proactivity
2) Collaborative Conflict
3) Containment

I will address proactivity today and discuss the other parts of the strategy in subsequent ezines. Hospital executives bring considerable resources to the table. As a result, negotiations with physicians do not need to become defensive. Here are some examples of what hospital executives can offer:

Access to capital at a lower rate of interest than physicians generally can obtain on their own
Participation advantages in the purchase of expensive, rapidly changing high-tech equipment, such as CT and MRI scanners
Market power to obtain reimbursement from payers for cutting-edge services
Access to land near the hospital that the hospital may own
Experience with federal, state, and local regulatory agencies related to certificate of need, zoning issues, environmental impact, and compliance with Stark and anti-kickback laws
A known identity for patients that can provide comfort, security, and credibility

Used with permission from Better Communication for Better Care: Mastering Physician Administrator Collaboration, by K.H. Cohn. (Chicago: Health Administration Press,2005)18-19.

Points to remember include:

Most physicians are putting up money to be used for children’s education, weddings, or retirement and thus want to minimize risk and uncertainty
Nothing in medical school, residency, or fellowship prepares physicians for business ventures
Physicians generally want to be part of deals that give them increased control over scheduling and increase the volume of patients that they can see and treat in a given day
Outside turnkey promoters’ percentage fee of gross revenues may eat up a substantial share of physicians’ profits
Money that goes to outside national chains generally leaves the community rather than being reinvested in local institutions

If new medical ventures were easy, they would be even more widespread than they are now. In the next ezine, I will cover communication issues and hot-button words to avoid.

3) Hot-Button Words to Avoid in Healthcare, 4/07

A West-Coast internist wrote that health-care professionals could benefit from “interventional marriage counseling” because they talk at rather than to each other, not hearing what the other side is saying. Although the reasons are multifactorial, hot-button words, such as “but,” “just,” and “you” can stress relationships and interfere with collaboration.

But
How many of us have at some point in our life felt damned by faint praise that begins, “You did a great job, but …” What do we remember? The next time that person interacts with us, we put up an invisible shield, expecting criticism. My daughter became so infuriated by this approach that she yelled, “Don’t wave your ‘but’ at me!” She has taught the family to use more emotionally neutral words like “and” or “at the same time” to make contrasting statements.

Just
At least once a year, a well-meaning person asks me, “What type of surgeon are you? Do you specialize, or are you just a general surgeon?” I parrot the words “just a general surgeon.” Perhaps “just” should be used to apply to justice rather than to describe another professional’s actions, attributes, or implied value.

You
“You suck,” a young family practice physician roared at an older physician whom he felt was patronizing him at an off-site retreat. The silence in the room was palpable. After approximately 20 seconds, which felt like 20 minutes, the new department chairman tentatively said, “Dr. Cohn taught us to send ‘I’ messages.” The young physician glared at me and, with reddened face and neck, looked the older family practice physician in the eye and said, “I feel you suck.” Everyone in the room laughed in relief and, from then on, understood the difference between “I messages” and the more accusatory “you” messages.

Points to remember include:

Conflict is inevitable in rapidly changing settings like healthcare
Being conscious of hot-button words can decrease the chance of conflict escalating to the point that it interferes with providing collaborative, patient-centered care

4) Keys to Successful Electronic Healthcare Record Implementation, 6/07

At a recent conference, a vendor remarked wistfully that the process of implementing an electronic health record is only 20% technology and 80% change management, process improvement, and physician engagement. On page 59 of their book, The Executive’s Guide to Electronic Health Records, Chicago: Health Administration Press, 2007, http://www.ache.org/pubs/smaltzoffer.cfm,
Smaltz and Berner quote an article in Computerworld dated November 8, 2004 that states that only 29% of IT projects achieved their envisioned benefits.

Jha et al. wrote that only about 1 in 4 physicians use electronic health records and fewer than 1 in 10 use them as efficiently as possible (Health Affairs 2006:25:496-507). Part of the reason for physician skepticism and resistance is that the benefits of electronic health record implementation accrue indirectly to physicians via ease of data retrieval and improved clinical outcomes. A recent NY Times article “Who Pays for Efficiency,” stated that physicians get only 11% of the savings generated by electronic health records, with the major dividends accruing to payers. (http:www.nytimes.com/2007/06/11/business/businessspecial3/11save.html)
The steep learning curve means increased time making rounds, which is already in scarce supply.

The key to a successful electronic health record implementation process is proactive physician engagement. This process needs to be done with, rather than to, physicians. The authors remind us that the IT department should serve as facilitators for physicians to improve their workflow and that the hospital should compensate physician champions for their time working on the order and decision phase of the electronic health record (p.57). Physician champions should be established clinicians who are well-respected by their colleagues, not techno-geeks.

Identify the top 20% of physicians, who regardless of their irascibility, account for 80% of admissions or 80% of revenue and approach them well before the go-live date to help them customize the way that they view inpatient data. Show them how to log-in remotely and follow up with them at regular intervals to identify speed bumps, such as problems with interfaces connecting them to laboratory, pharmacy, and radiology systems, which should be resolved with simulation as much as possible prior to the go-live date.
Allow physician users to go into the “moan zone” initially rather than being defensive or taking their remarks personally. Their comments may be a symptom of pain and emotional overload that will resolve if treated supportively and empathetically.
Finally, show that you respect physicians’ time by providing assistance when and where they desire it, especially in the early implementation phase, with trainers present at the times physicians make rounds, making sure that there are adequate terminals, so that physicians do not need to wait in line to enter orders and notes. Having the IT staff available periodically when physicians make rounds is an investment rather than a cost of doing business.

Points to remember include:

Automated, efficient back-end systems in laboratory, pharmacy, and radiology must precede electronic health record implementation
Involving physicians in improving inefficient care processes prior to implementation is key to successful electronic health record functionality
Encouraging physicians proactively to customize the way that they view patient data, alerts, and reminders decreases resistance and speeds adoption

5) Keys to Understanding the Relationship Between Primary Care and Hospital Revenue, A Summary of Marc Halley’s New Book
The Primary Care-Market Share Connection: How Hospitals Achieve Competitive Advantage, by Marc Halley, Chicago, Health Administration Press, 2007, www.ache.org/hapShareOffer

Points to remember include:

The true measure of market share is the number of primary care physicians (PCPs) who refer patients to a hospital and its affiliated specialty physicians.
Relationship management is key to attaining sustainable competitive advantage
Sustainable competitive advantage requires that successful organizations remember their fundamental purpose: to create and keep customers, which comes down to the right targets, right processes, and the right execution daily

Summary:

p.6 Hospital CEOs need to focus on PCPs who create loyal groups of customers for hospital and its specialists by building long-term relationships with their patients

p.19 Most patients have difficult time recognizing clinical competence and quality; providing great clinical care is necessary but not sufficient in today’s consumer-driven environment, where convenience, accessibility, and responsiveness matter; moments of truth involve key episodes where patients come into contact with healthcare professionals and form lasting impressions (p.45)

p. 21-2 Patients generally do not self-refer to specialists and depend on medical professionals to refer them to specialists; complexity of care perpetuates this dependence; PCP referrals to specialists are usually based on past experiences, friendships, and recommendations from other PCPs in their practice rather than personal witness to specialist’s skill

p. 25-27 In competitive markets, providers sustain competitive advantage by making patients the center of their universe; retail readiness requires: positive word-of-mouth, knowledge of patients’ needs, wants, and priorities, convenience, providing high-quality information, setting expectations, customer service training, measuring the customer experience, and viewing complaints as opportunities to improve quality and service (see Appendix A: retail readiness questionnaire)

p. 31-3 Primary care = market share, which must be understood by all members of the demand chain; loftiest mission statement is irrelevant unless organization is able to find and keep patients to care for

p.62-9 very few organizations can prove that they have the best physicians; to retain referral base, specialists need to demonstrate convenient access and respect by acknowledging referral, engaging the PCP in treatment decisions, sharing knowledge and expertise, and returning patient to PCP for f/u care

p.93-95 foundation of successful physician-hospital partnerships is mutual purpose, incorporating mission, vision, values, strategies, and tactics to produce consistent clinical quality, outstanding service, financial viability, and mutual benefit; successful partnerships are characterized by true dialogue- the ability to identify what is right rather than who is right

p. 125-7 Demand-chain management is a process to attract and retain market share, not an event; collaboration will increase the size of the pie; use following steps:

Ask what is working well?; talk to clinically respected physicians about their needs, wants, and priorities; identify referral patterns and rationale; learn their expectations of other physicians re: access, dialogue, and outcomes
Engage service-line physicians re: hospital’s retail strategy and demand-chain management, meeting monthly to review service-line performance and share best practices
Improve performance
Broaden physician participation; use established service line program to improve demand-chain management in a different service line, using physicians as educators

p.143 Organizational change brings out the best and worst of every culture; fundamental indicator of organization’s ability to assimilate change is whether the organizational culture requires individual accountability for performance; 2 types of performance accountability: to patients and referring physicians and to other members of the demand chain; people must be willing to discuss performance shortfalls, share best practices, and change behavior; important to distinguish between activity and outcomes; successful demand chains never occur by chance (p. 155); accountability requires an accounting

p. 144 Questions to ask:

Did you accomplish what you committed to?
What barriers did you encounter?
How soon can you accomplish the work?

p.146-50 Building a culture of accountability requires:

Effective sponsorship: the willingness to sanction organizational change, breaking from the status quo and overcoming barriers to implementation; sponsors set performance standards and exemplify performance
Shared purpose
Clear performance targets, deadlines, and measurement systems to achieve short- and long-term objectives
An effective implementation team
A players who are not afraid to hire other A players; assisting others to improve performance; hire slow/ fire fast

6) Cutting-Edge Physician Recruitment Strategies, 12/07

Overview

Your ability to recruit and retain physicians is key to your organization’s ability to function in an increasingly competitive marketplace
Considering all specialties, physicians generate on average $1,500,000 annually
The longer it takes to fill key positions, the less revenue you have to fulfill mission-critical responsibilities

Put technology to your advantage

Invest in a website that makes it easy to interact with people
Dedicated Physician Recruitment web pages
Job search function by specialty and location
Direct contact to the appropriate recruiter
Feature that allows candidates to apply on-line
Video clips
Virtual tours
Audio testimonials from recent recruits and long-term happy physicians
Maps
Links to topics of interest
Make a recruitment compact disc or DVD with passionate physicians and employees talking about why they love working at your organization and how long they have been there
New technology allows candidates an interactive experience
Create specialty specific CD’s, where applicable
Search where people are looking for jobs
Many sites have searchable database capabilities
Sites include:
- practicelink.com (oldest and largest)
- physicianwork.com
- docjobs.com
- aspr.org
- Physician professional association job boards (eg. www.aafp.org, www4.aaos.org/member/placement, www.acc.org, www.acr.org )

Make your interviewing process stand out

Do everything better than your competition
Planning your interview process well in advance will make it easy for physicians to come for interviews

Develop a core group of interviewers

Interview all candidates in a consistent manner
Train your core group to become expert interviewers and evaluators
Use your most convincing physicians to sell people on reasons to work at your organization
Break up topics, making each interviewer responsible for one area of evaluation during the time-slot:
- Practice style
- Clinical competence
- Interpersonal skills
- Knowledge and understanding of the business of health care
Strategically plan the sequence of who interviews and when
- Open and close interviews with strong, high-level leaders
When possible, remove interviewers incapable of being enthusiastic salespeople
- At a minimum, give candidates a “heads-up” about what they may hear in the interview PRIOR to their visit

Select vendors used consistently

Travel agency
Hotel
Restaurants
Realtor
- Set up direct bills with vendors, so that candidates do not have to go through a lengthy reimbursement process
- Create a diverse group of happy physician spouses to meet with candidates’ spouses for lunch and a community tour

Clinch the deal with your offer

Always make a verbal offer first
Get the candidate to give you a verbal acceptance (commitment) BEFORE a written offer is sent
Position yourself to be able to offer slightly more than what the candidate expects the offer to be
Include in your contract or letter of offer a “date of expiration” (1-2 weeks)
Timeliness in executing the offer process is critical
- Have the details worked out and the paperwork done prior to the offer being made

7) A Creative Way to Engage Physicians, 2/08

In response to a frequently asked question, “How can you engage physicians who do not want to have anything to do with the hospital?” a physician colleague responded:

“If they do not want to have anything to do with you, ask them why not!!…..that is a definable set of reasons and (mis)perceptions you might have to dig out of them, realizing that you might not like and may not want to hear what they say, but once understood gives you something to work with.”

This approach is a variation on taking the first step: admitting that we do not have all the answers and seeking feedback that may hurt because we take personal pride in our efforts to care for patients.
Some times, however, it takes unconventional approaches to obtain breakthrough results, as the following story illustrates:

Leon Bender, 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%.

A breakthrough occurred at a meeting of physician leaders, when the epidemiologist at Cedars Sinai cultured physicians’ hands, photographed the bacteria on the Petri dishes, and turned 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.” (Dubner and Leavitt 2006).

The distinction between what physicians and nurses principally do (care for patients) and what administrators principally do (finance, operations, marketing) is blurring. Recent decisions, at the Center for Medicare and Medicaid Services (CMS) not to reimburse hospitals for complications, such as catheter acquired urinary tract infections, bedsores, and falls that occur in the hospital, compel us to put aside significant differences in background, training, and outlook and place patients and families at the center of our joint universe.

©2008 Kenneth H. Cohn, M.D., MBA, FACS
Reference
Dubner SJ, Leavitt SD. 2006. “Selling Soap.” [Online publication, accessed 12/8/07]. http://www.nytimes.com/2006/09/24/magazine/24wwln_freak.html?_r=1&ex=1160020800&en=0c4817f1e4d7f211&ei=5070&oref=slogin#

8) Engaging Physicians in Improved Marketing Efforts, 4/08

Although many physicians may focus on advertising as marketing or promotion, they recognize the importance of understanding and meeting or exceeding the needs of patients in their communities. Patients often follow physicians’ advice regarding where to seek care. Physicians need to know what services other physicians offer to promote their services. Hospital leaders can play an important role in facilitating information sharing, as seen in the following examples:

1) Encourage practicing physicians to articulate future clinical priorities

“I can’t believe it,” roared a Connecticut internist at a Medical Advisory Panel presentation, his fist pounding the table, after he heard a vascular surgeon describe 11 patients with weaknesses of the main blood vessel in the abdomen who were treated successfully with minimally invasive stent grafts rather than open operations.

“I have sent 4 patients with abdominal aortic aneurysms to an academic medical center in the last two months because I did not even know that we were doing minimally invasive vascular procedures here. We need to do a better job communicating!”

On the strength of the internist’s recommendation, physicians gather quarterly for an evening medical staff meeting, of which the first order of business is an update on new services. Attendance has remained high at medical staff meetings for the last decade because this approach to new services continues to meet physicians’ needs.

2) Include doctors who are users of radiology, anesthesiology, pathology, and emergency services to draw up contract specifications and monitor performance

A hospital leader in Colorado listened when physician users of contract services complained that physicians providing contract services displayed suboptimal performance and responsiveness to patients’ and physicians’ needs.

Rather than feeling trapped in the middle, the hospital CEO arranged for physician users to help him draw up the performance specifications, rewards, and penalties. This process has continued despite the CEO’s departure because it improved physician-physician communication as well as the hospital’s ability to market its contracted services to its entire population of physicians. Rather than lose-lose negotiation, in which everyone gives up something, this negotiation has been a win for patients, families, physicians, and the hospital.

3) Take waste out of the system by mapping steps of policies and procedures to improve effectiveness and refine handoffs

A Midwestern hospital leader learned that his leading orthopedic surgeon was considering building an ambulatory surgical center (ASC) to prevent losing patients to competing groups who offered faster time to operation. This sports-medicine specialist showed data that he could double his output over the next year with an ASC. The hospital leader engaged a multidisciplinary task force to analyze the process of care from preadmission to discharge and follow-up appointments, using a low-tech approach of writing every step on a large post-it note, posting the steps on a wall, removing unnecessary steps and rework, and simplifying burdensome processes.

The task force was able to pinpoint how the current non-system actually worked and to redesign a more efficient process that did not require hiring additional personnel. The orthopedic surgeon decreased patients’ waiting time and increased his productivity approximately 50%. For the past two years, the orthopedic surgeon has been satisfied with the performance and has not built an ambulatory care center.

Seeking to establish a branded identity is challenging and expensive. Only by understanding patients’, physicians’, and hospitals’ changing needs can physicians and hospital leaders collaborate to improve care for their communities. Joint presentations to community groups by physicians and hospital leaders can improve communication, promote goodwill, and build business.
©2008 Kenneth H. Cohn, M.D., MBA, FACS

9) Engaging Physicians in Cutting Expenses 8/08

When I teach graduate students in health administration, I pose the following question to them: “What is the most expensive device at your hospital?” Invariably, they reply the MRI scanner, CT scanner, or PET scanner. They look at me dumbfounded when I tell them that the physician’s pen dictates the majority of their hospital’s expenses.
Yet, if physicians can be viewed as the problem, they also can become the solution, as seen in the following examples:

1) Ask a physician advisory panel for help

A CEO at a Rocky Mountain tertiary care facility asked the Medical Advisory Panel formed at his hospital for advice on how to cut supply costs. The panel responded affirmatively to his request stating, “Only physicians have the clinical knowledge to identify cost savings that do not compromise patient care.” They have worked together with an interdisciplinary supply cost reduction group to achieve over $500,000 in ongoing supply cost savings in the purchase and utilization of orthopedic implants, heart valves, radioisotopes, and anesthetic and cardiovascular medications.

This story shows that if one treats physicians as adults, one can obtain adult behavior. If you want more information, please ask me for my article, published in HFM.

2) Take advantage of healthy competition among physicians to decrease variability and expense

The medical director of a Northeastern cardiac catheterization laboratory faced an ongoing problem. The proliferation of supplies was creating storage problems as well as limiting the lab’s profitability. He knew that closing down a procedure room to add storage space would limit opportunities for future expansion of programs and services. Now that the new information system was coming online, he was being questioned not only about supply costs but also about procedure times and outcomes of his staff of six invasive cardiologists.
Not certain what to do but convinced that ignoring the challenges was not an acceptable solution, he turned to his cardiology colleagues at a staff meeting and asked for their input. He showed simple bar graphs of procedure times for balloon dilatation and stenting by anatomic location and number of stents for each of the cardiologists who were identified by number rather than name. Only he knew which name corresponded to each number.
The cardiologists agreed that they could see widespread differences. Supply use also was dissimilar among physicians. Data on simple outcomes like myocardial infarction and death according to American Heart Association category and elective vs. emergent status, revealed substantial variation. He encouraged the group to share their thoughts in subsequent group meetings on how they might limit variation, improve outcomes, and cut supply costs, telling them that they would re-examine the data in another four months, hoping to see progress. If they could not come to consensus on how to limit variation and improve outcomes and profitability in six months, he would put names above the individual physicians’ numbers and post the data on a bulletin board in the catheterization laboratory in full view of the entire staff.
The medical director’s clinical credibility, integrity, and sincerity were unchallengeable. Within four months, procedure times and outcomes for the entire six-person group were within one standard deviation, and the staff had decreased their vendors to two and cut costs substantially, all while improving outcomes. As one of the cardiologists explained, “None of us wanted to be an outlier, except on the positive side.”
Reprinted with permission from “Engaging Physicians in Hospital Operations,” in Cohn KH. 2005. Better Communication for Better Care: Mastering Physician-Administrator Collaboration. Chicago: Health Administration Press, 46-51, http://www.ache.org/pubs/redesign/productcatalog.cfm?pc=WWW1-2038.

3) Use a palliative care team to decrease suffering and expense

A Connecticut community teaching hospital has found that by making a palliative care consultation standard on all admissions to their ICU that they can assuage family members’ needs to have everything done for their loved ones and cut unnecessary costs and length of stay. This service has also been a wonderful morale booster for nurses who otherwise might feel uncomfortable responding to families’ questions.
©2008 Kenneth H. Cohn, M.D., MBA, FACS

10) Physician-Hospital Relations in the News: Four Keys to Sustainable Collaboration 10/08

I agree that both physicians and hospital leaders feel that they are working in a state of siege and that the confluence of declining reimbursement amid rising expenses, complex regulations, and heightened consumer expectations make conflict inevitable. Occasionally the tensions between patient survival and organizational survival can make us forget that we agree on the “who” (patients) and “why” (to make a difference in patients’ lives) as we go through the iterative journey of the “how,” as I described in my blog post http://healthcarecollaboration.com/collaborative-indifference/.

I think that it is unfortunate that our differences of opinion are inaccurately linked to 98,000 patient deaths per year and offer four keys to physicians and hospitals working more interdependently to improve care for their communities.

1) Use transparency to build trust
Trust is a card house that takes years to build and only a puff of suspicion to blow to pieces. We frequently personalize differences in training, outlook, and values with inflammatory statements like, “He lied to me.” However, participating in interdisciplinary projects that benefit patients can bring vital sunshine to processes that previously were cloudy. Transparency can be a bridge to building vital trust and mutual respect.
The patient safety movement offers multiple examples, such as the work of the Pittsburgh Regional Healthcare Initiative which was among the first regional initiatives to decrease central-line infections, hospital readmissions, and medication errors. As Dr. Richard Shannon, Chair of Medicine at Allegheny General Hospital, said:
“I believe that if we eliminated medical errors, there would be no malpractice…, but the work begins with us. The work begins at the patient’s bedside. The work begins with the people that provide the care. The work begins by listening to what they know about how to make things better, not the historical top-down approach.”
(Cohn et. al. “Taking a Proactive, Collaborative Approach to Malpractice Issues,” in Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives, http://healthcarecollaboration.com/books/).

2) Cultivate physician champions
Physician champions are outstanding clinicians who have earned the respect of their peers by caring for patients in a consistent and reliable fashion, delivering great clinical outcomes. They are the people we turn to when we need medical care. They are also seasoned professionals looking to leverage their knowledge and experience to improve care for their community. (http://healthcarecollaboration.com/collaborative-champions/)
Possible roles for physician champions include:
- Presenting and discussing clinical data with fellow physicians
- Minimizing physician-hospital battles
- Creating a safe environment for learning
- Helping to build transparency and trust, as discussed above

3) Respect one another’s time
Showing respect for one another’s time goes beyond punctuality. It includes closing the loop on issues that are brought up, even if they are outside of our usual and customary duties but involve patients’ well-being. Keeping such activities on a dashboard reminds busy professionals of commitments yet to be delivered.

The way physicians deal with implementation issues is the way that they learned in residency with a “scut list” that describes the task, person (not committee) responsible, and the timeline. Long-term projects are OK if the steps are chunked into 2-3 week action items. Outcomes are physicians’ daily currency, and we are suspicious of process because we have had no formal training in process measures in medical school, residency, or fellowship.

4) Make time to celebrate successes
Gathering people together who contributed to a project’s success makes it easier to work together the next time. Informal communication at such events may prevent the next crisis from happening. These celebrations provide a way to publicly acknowledge people who went beyond their job descriptions to improve patient care and thus help build the culture to support recruitment and retention of outstanding healthcare professionals.

What activities have you found helpful in improving physician-hospital relations? Please send them to me at ken.cohn@healthcarecollaboration.com, and I will include them in my next quarterly ezine.
©2008 Kenneth H. Cohn, M.D., MBA, FACS

11) Coming to Your Community Soon? CMS Global Fee Demonstration Grants 11/08

In Colorado, Oklahoma, New Mexico, and Texas, the Center for Medicare and Medicaid Services (CMS) has begun a demonstration grant process to look into global fees, in which CMS will contract with a group of providers to accept a single fee for all medical services delivered for a single episode of care.

In January 2009, approximately 20 cities will participate in the Acute Care Episode (ACE) Demonstration Project, where a single group of physicians and hospital(s) accept a global fee for up to 37 Medicare-Severity Diagnostic Groups (MS-DRGs) in cardiac and/or orthopedic surgery.

When I discussed this scenario last month with a group of hospital leaders who participated in my ACHE seminar “Practical Strategies for Engaging Physicians,” their body language was telling. Despite their discomfort, they participated avidly in the discussion. At the end, although none felt ready to accept a global fee, they came away with a series of steps to begin the journey.

They felt that even though this project was a demonstration grant, that the handwriting was on the wall, especially with a second demonstration grant expected to be announced in 2009 in another part of the US. The likelihood is high that commercial insurers are watching with interest and expect to join in once the data show that they can save money.

The implications are that global fees will create two classes of providers: those that can adapt to the new system and thrive and those for whom the bathtub water is swirling. My seminar participants believed that the successful providers will realize that:

• Global fees are an opportunity to improve physician-physician as well as physician-hospital communication
• Physicians and hospital leaders must pay at least as much attention to enlarging the pie as dividing it
• Shared values, based on the needs of the community, will eventually dominate the discussion
• What is right for the community will transcend who is right
• Physician advisory groups, comprised of physician champions who have earned the clinical respect of their colleagues, will lead the discussion
• New physician leaders will emerge through this process
• The practice environment will improve for other MS-DRGs as a result of the process
• When physicians are treated as adults, with access to data and authority to participate meaningfully in clinical priority setting, they behave like adults, with active participation and sensible recommendations
• Through the process of discovery, physicians can begin to act as responsible stewards (and perhaps owners) of scarce community and hospital resources

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