Congratulations ... you're fired!

Being fired as a physician executive is the dark side of burgeoning opportunities for health care leadership. The risk of termination is 20 to 40 times higher than for clinicians. Several approaches to calculating and predicting the probability of being fired are presented, based on a recent survey of American College of Physician Executives members and the author's professional observations. The survey identified several factors that are associated with a higher risk of being fired. These include structural conditions like organizational type and position, as well as factors ranging from being the first person in a new or unclear job to working for an entity with two or more years of significant financial losses. Persistent conflict with a boss or board member--concerning personal style or organizational strategy--is another commonly present danger signal. Additional predictive variables include recent termination or departure of a boss, recent merger, and widespread organizational downsizing or re-engineering. This article suggests strategies to better predict high-risk situations, to prevent termination, and to increase the likelihood of your professional and personal well-being when termination becomes inevitable.

Physician anger: Leggo dem managed care blues--leadership beyond the era of managed cost.

While managed care has caused great disruption, it has also provided physician executives with a natural leadership raison d'être. Managed care, with all its pros and cons, is largely a response to certain unrelenting trends. The core functions of leaders comprise the stewardship of organizations and colleagues in response to these trends. Four trends are explored: (1) The demise of open-ended funding of American health care; (2) continued competition for health care resources; (3) thriving pluralism; and (4) patients continually adjusting to assure themselves of appropriate health care access, quality, and service. In the 21st century, the industry will need a new brand of leader, one capable of balancing the needs of the professionals with the business and accountability requirements of a permanently competitive and resource-constrained service industry. The keys to successful leadership in the future include: (1) Clear service differentiation and a compelling vision to match it; (2) recruiting and retaining top clinical talent, including the required return to physician self-direction and governance; (3) successful partnerships with others outside your organization; and (4) a steady focus on performance in all its dimensions.

Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State.

The perceived relationship between primary care physician compensation and utilization of medical services in medical groups affiliated with one or more among six managed care organizations in the state of Washington was examined. Representatives from 67 medical group practices completed a survey designed to determine the organizational arrangements and norms that influence primary care practice and to provide information on how groups translate the payments they receive from health plans into individual physician compensation. Semistructured interviews with 72 individual key informants from 31 of the 67 groups were conducted to ascertain how compensation method affects physician practice. A team of raters read the transcripts and identified key themes that emerged from the interviews. The themes generated from the key informant interviews fell into three broad categories. The first was self-selection and satisfaction. Compensation method was a key factor for physicians in deciding where to practice. Physicians' satisfaction with compensation method was high in part because they chose compensation methods that fit with their practice styles and lifestyles. Second, compensation drives production. Physician production, particularly the number of patients seen, was believed to be strongly influenced by compensation method, whereas utilization of ancillary services, patient outcomes, and satisfaction are seen as much less likely to be influenced. The third theme involved future changes in compensation methods. Medical leaders, administrators, and primary care physicians in several groups indicated that they expected changes in the current compensation methods in the near future in the direction of incentive-based methods. The responses revealed in interviews with physicians and administrative leaders underscored the critical role compensation arrangements play in driving physician satisfaction and behavior.

An evidence-based approach to evaluating and improving clinical practice: implementing practice guidelines.

Clinical practice guidelines can improve health care outcomes, but they are only as effective as their implementation. We present a framework for implementing practice guidelines that begins by identifying the forces driving and restraining the adoption of the guideline. Strategies for changing physician behavior that strengthen the driving forces and weaken the restraining forces can then be incorporated into a comprehensive implementation program. Nine strategies for changing physician behavior are presented, based on a review of the literature and organizational experience at Group Health Cooperative of Puget Sound. In designing an implementation strategy, it is essential that the resources allocated to implementation are commensurate with the improvement in outcomes expected from the successful implementation of the guideline. All implementation programs should include plans for measuring outcomes to allow for continuing improvement. Guideline implementation, evaluation and improvement efforts are most likely to be successful when they are part of an explicit, evidence-based process for evaluating and improving clinical practice.

Quality management in a staff model HMO.

Group Health Cooperative of Puget Sound is gradually developing a quality management approach to the delivery of health care. Derived from the strong commitment of its medical staff and operations management to providing optimal health care and building on the best aspects of traditional quality assurance, the quality management approach provides a realistic program that makes a meaningful difference to the quality of patient care. This paper describes the various components of the evolving approach including physician performance management, departmental activities, multidiciplinary review, and the activities of the centralized office of quality of care assessment and regional quality action committees.

Mirror, mirror on my desk.

Physician executives, perhaps more than typical business managers, are often generally cognizant of their own personalities and their relative strengths and weaknesses. However, as with most matters with which one has intimate familiarity, we are less clear about the specifics of our personality styles and their most effective use. This article discusses a model for using personality assessment and developmental and historical interviewing in the education of physician executives. Examples show how personality assessment can be used by physician executives in a voluntary and safe way to enhance professional development and career decision making.

Costs and benefits of medical student training to a health maintenance organization.

As health maintenance organizations (HMOs) and managed health care systems expand, they represent an increasing potential as sites for medical student teaching. Considerable difference of opinion exists about the impact of medical training on these prepaid delivery systems. This study presents a methodology for estimating the subjective and objective costs and benefits of medical student training to an independent staff model HMO with a long-standing training program. Data are derived from a provider survey, a consumer survey, and patient visit logs. Principal subjective benefits include increased perceived quality of care, improved patient satisfaction, and enhanced provider education and joy of practice. Objective impacts include a decrease in productivity of 1.1 patient visits per half day and direct physician teaching labor of 46.8 minutes per half day. Applying this methodology to the specific program of ten courses gives rise to a figure of $180 000 ($16 900 per full-time equivalent student per year) for the "opportunity cost" of medical student training to the HMO. Rules of thumb are developed for application of this method prospectively to new programs in similar relationships between staff model HMOs and academic medical centers.

Changes in physician behavior and cost savings associated with organizational recommendations on the use of "routine" chest X rays and multichannel blood tests.

Group Health Cooperative (GHC) of Puget Sound is a prepaid health plan with 285,000 enrollees and 340 physicians. In 1978 a "criterion analysis" approach was instituted to develop medical staff recommendations about preventive care. By 1979, two recommendations evolved discouraging the "routine" use of: (a) chest X rays (CXR) and (b) multichannel blood tests (MCBT) in asymptomatic adults at "routine" physical exams. An extensive educational campaign was conducted to change physician behavior in use of these tests. Usage patterns were measured both before and after the recommendations and educational programs. A fivefold fall in "nonindicated" use of CXR and a 1.5-fold fall in MCBT occurred. A cost savings of $166,582 (annually) resulted from this diminution in "nonindicated" testing. The decision-making process and educational campaign technology hold promise for GHC's preventive medicine program in the future. These results may have applicability to other health care organizations.

Teaching sigmoidoscopy to primary care physicians: a controlled study of continuing medical education.

A sigmoidoscopy skills preceptorship was developed for physicians to increase the rate of sigmoidoscopy by physicians in a health maintenance organization. The preceptorship was designed as a randomized, controlled study of continuing medical education. Baseline sigmoidoscopy rates of participating physicians were similar to those of nonparticipants, as were selected demographic and professional characteristics. Physicians randomized to receive sigmoidoscopy training significantly increased their rate of sigmoidoscopy when compared with controls. The proportion of barium enemas accompanied by sigmoidoscopy likewise increased. All physicians who participated improved when compared with nonparticipants. The sigmoidoscopy skills preceptorship appears to be a worthwhile endeavor in continuing medical education.