The End of Us vs. Them

Philip Betbeze, for HealthLeaders Media , April 13, 2012
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Put physicians in charge
A saying that has been around for years in healthcare goes like this: There are the suits and the white coats, and the twain shall never meet.

That stalemate won't be broken until physicians are more liberally placed in top-level positions—and the doctors are prepared to face business challenges, says Kirch.

"Only relatively recently do we have the advantage of people trained to wear the white coat who are more able to assume those executive positions," he says. "In terms of the rapidity of change, a lot of it is being stimulated by economic forces. When you have docs moving this rapidly into employed status at the health system, you need leaders who can speak their language and understand their world."

Even at smaller hospitals like Ogden, independent physicians are taking ownership of challenges that in the past might have simmered for years as a source of discontent. A little more than a year ago, Ogden's senior leadership began to have serious concerns about limitations in the OR. Much of the increased demand was coming from growth in the region and community, but that led to serious capacity limitations. Although the facility performed nearly 6,500 procedures per year with seven operating rooms, the surgical schedule was blocked at 89%.

"We had a very highly blocked surgery schedule that did not allow for flexibility with open/elective cases," says Adams.

The hospital was losing referrals amid a ramp-up of a urology service line initiative, had opened a new orthopedic unit in the hospital, and faced a growing level of demand from the cardiovascular service line. 

"All those factors together put us in a position to do something different," he says. "Docs who already had block time were happy, but others were not."

Ogden has about 300 physicians on the staff, with about 15% employed, so independent physicians are an important constituency. Medical and staff leadership met to discuss the bottlenecks and possible solutions—without the option of adding physical space.

Together, they decided to undertake a process improvement plan with the help of GE Healthcare Performance Solutions, with the idea that changes in policy and practice could open up significant time in the existing configuration.

In a departure from standard procedure, physicians held eight of the 10 positions on the OR block committee that developed the plan, but Adams says many other surgeons were skeptical about what the exercise could accomplish, given that previous attempts at policy and practice changes had achieved very limited results.

"We then went a step farther and formed an OR governance committee, to whom the block committee directly reports," says Adams. "They make final decisions on OR policy and practice."

That committee is made up of 13 members, of which three are hospital management staff and 10 are surgeons. (Each service line has one representative.)

"Previously, we would see input through the committee structure, and management would filter those and make the decision," Adams says. "This new structure sent the message that we wanted to engage them, and they feel and act more accountable to the recommendations, which we give them the authority to make. There still has to be give and take, and management is represented, but those two committees are largely responsible for the change in culture."

The change in culture led to a gain in prime-time (7 a.m.–3:30 p.m.) utilization from 69% to 81%, and Ogden's OR went from 89% blocked to 70%. That gave Ogden significant flexibility to add elective cases that did not meet block-scheduling criteria. On-time starts have also increased from 33% to 81%.

"That has huge implications on efficiencies and operations throughout the day," he says. "We still have some more to do efficiency-wise, but our goal was to try to get two years' additional capacity before physical expansion, and we did that."

The recovery of operating time has led to a potential increase of $3.78 million to the hospital's bottom line, he says, although final results are not yet available. But Adams and the surgeons were so pleased with the effort that he's rapidly trying to replicate this collaborative effort in the emergency department.

Get organized
Wasserman says the No. 1 goal for his clients surrounds methods of helping the physicians get organized around patient care and care coordination and begin to get them—whether they are employed or independent—into a structure where they can work as colleagues.

"Then take that structure and link it to the system. The second big goal concerns the incredible rise of the employed physician group," he says. "That doesn't mean alignment," he says, but hospital leaders are realizing that such equal governance partnerships help get physicians focused on improved care and cost reduction rather than quarreling among themselves or, worse, blaming the hospital for such problems.

"Leaders have realized that employing is not enough," he says.

On either side of this important debate, playing the blame game does no one, least of all the patient, any good. If you're pointing at your physicians for being obstinate, there are four fingers pointed back at you.

This article appears in the April 2012 issue of HealthLeaders magazine.

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Philip Betbeze is senior leadership editor with HealthLeaders Media.
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