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The Corporate Medical Director
MEDICAL DIRECTION IN LONG-TERM CARE
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THE CORPORATE MEDICAL DIRECTOR Keith Krein, MD
"Something unusual, puzzling and powerful, is about, and it shows no signs of stopping or even abating its influence. It is the phenomenon of change, and it is gaining on us."2 ROBERT D. GILBREATH
This article conceptually examines the role of the corporate medical director in three broad categories: (1) what is going on in health care today, and more specifically, what is going on within health care corporations that would suggest a need for this article, (2) what are the attributes of a successful corporate medical director, and (3) what would be the major themes composing the corporate medical director's primary responsibilities. EVOLUTION OF HEALTH CARE DELIVERY
Dynamic changes are occurring in health care throughout the world. Whether one is for, against, or indifferent to such changes is immaterial. If one is involved in health care, the paradigm shifts occurring today will significantly affect his or her life. The major change agent is a shift in focus from providers of care to purchasers of care. The purchasers are looking at controlled costs, increased access, and documented quality. All reporting health care systems share the same delivery problems, external (ever-rising costs) and internal (variable and inefficient care). The costs are partially driven by uncontrollable factors, such as the worldwide aging of the population, technologic advances, and profesFrom the Living Centers of America, Houston, Texas
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sional liability. In 1991, per capita health spending in the United States exceeded that of Canada by approximately 509'0, Germany and France by 75%, Sweden, Finland, Italy, and Australia by 10O0/0,Japan by 120%, the United Kingdom by 175%, and Spain and Ireland by 240%.1° Undoubtedly, the health care industry in the United States was very good, but its costs significantly outpaced other developed nations. In late 1992 and 1993, however, some amazing headlines began to capture the business pages of the nation's papers. The rate of increase in the medical care component of the Consumer Price Index actually began declining, reversing years of relentless increase. The political strategies of the early 1990s focused the nation's eyes on health care, specifically its cost and availability. Business entities saw this situation as an opportunity to create more efficient ways of providing health care services. Hospital occupancy rates steadily declined as alternative, more efficient sites of care developed. Specialists who performed large numbers of medical procedures or who billed for them at very expensive rates were also targets for innovation. Even the need for such large numbers of specialists was questioned because specialists represented a far larger proportion of physicians in the United States than in other countries whose health status appeared equivalent. The fee-for-services paradigm had started to change. Therefore, there are three realities for tomorrow's health care delivery system. First, controlling costs will drive the system. Because the aging world population is recognized as one of the uncontrollable factors driving cost, this issue becomes of paramount importance for those involved in geriatrics and long-term care. There are controllable factors, however, that drive costs as well. Those that claim quality health care and cost effectiveness are mutually exclusive should study the works of Deming, Crosby, and Juran. There is ample evidence to suggest that opportunities abound to reduce waste and rework and eliminate variability in the health care system. So what drives the controllable costs? Thousands of varied components drive costs from high-tech to hightouch, but the particulars are inevitably traced back to the physician's assessment and plan of care, including diagnostic tests and therapies-strong argument for physician involvement in managing the process. Second, alternative sites of service and niche strategies for care will abound. Over the last decade, an array of services has been carved from the hospital domain. Ambulatory surgery centers, home infusion companies, rehabilitation centers, and respiratory hospitals are just a FAT AS hnsnitalq rontim~eto evolve as vlaces of highlv technologic diagnostic interventions and invasive procedures, much of the preparation for and recovery from such experiences will occur elsewhere. Today, included in the growth and development stages of the geriatric health care service life cycle are Medicare-skilled nursing, specialized units for Alzheimer's programming, adult day care, assisted living (even dementia-specific assisted living), and subacute care focusing on rehabilitation therapies for orthopedic, stroke, brain and spinal cord injury, amputee,
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arthritis, and pain management patients. Another branch of subacute care focuses on more medically complex patients, such as those requiring pulmonary care, wound management, complex intravenous administration, postsurgical care, and cancer to name just a few. The list grows as hospital stays shrink. The involvement of corporations in this alternative-site-of-care phenomenon becomes manifest in the concept of Integrated Delivery Systems (IDS).9Through the 1970s and 1980s, health care corporations took advantage of horizontal integration as an effective strategy for controlling costs. For example, many health care organizations realized that growth through carefully planned acquisitions and mergers could keep fixed overhead costs in check or even reduced. Overhead reduction occurred as efficient centralized departments, handling such necessary functions as payroll, accounts receivable, accounts payable, and purchasing, absorbed the extra work into their existing systems while allocating overhead among a greater number of facilities, thereby reducing the per patient cost. Likewise, the larger the number of employees or patients, the more power was wielded at the bargaining table to negotiate everything from food to equipment and supply purchases. Today, vertical integration strategies are being developed, such one corporation owning or managing care at multiple acuity levels (acute, subacute, long-term care, assisted living, or home health). In this strategy, patients can be moved through the continuum of care as necessary, avoiding the dilemma of a patient being needlessly maintained in a high-cost center when a lower-cost center would be equally appropriate. Theoretically, in a seamless, vertically integrated system, patients would be readily transferred from one site to the next, as dictated by their medical needs. The complexities of such a system obviously require physician involvement and expertise (supervision). Third, an emphasis is placed on primary care physicians to appropriately refer patients through the emerging maze called the health care continuum and is gaining momentum. Obviously, professional liability issues must be addressed in this changing scenario. There will be an increasing need for competent physicians with business acumen and management and leadership skills to be liaisons between the purchasers and providers of health care, such as between the medical staff and board of directors. A philosopher once said, "Control your own destiny or someone else will!" This quote is apropos for today's physician community, and it leads to the premise that physicians and health care institutions that prepare proactively will thrive; others will not. ATTRIBUTES OF A SUCCESSFUL MEDICAL DIRECTOR
Presently, there is a growing place in health care for physicians with leadership and management skills (e.g., corporate medical director or physician executive). Before discussing the responsibilities such a
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position would entail, there are some attributes that would engender success. In this regard, it is imperative to compare and contrast the dual role of the physician as clinician and the physician as manager. Michael E. Kurtz, MS writes persuasively and with extraordinary insight regardA thorough understanding of this subject matter is ing this dual vital to the success of any physician contemplating an executive role in a health care corporation. Today's corporate medical director also receives a business title such as Vice President of Medical Affairs or Vice President of Professional Services. In a large corporation, this means that the physician will be one of a dozen or more vice presidents. It is also quite likely that all the other vice presidents have had extensive business, financial, and managerial training, including postgraduate degrees. In order to effectively contribute to and communicate with these organizational peers, physicians must understand how their previous "world" (education, training, peers) differs from that of their newfound business associates. Physicians are significantly influenced by the values and norms of the world of medicine. The most formative years of their professional lives are spent in this "rite of passage" that shapes their view of the world as practicing physicians. These learned behaviors are successful for them and necessary if they are to achieve the desired outcomes and acceptance of their physician colleagues and peers; however, these same behaviors and characteristics can pose problems for the new medical director. Although it is certainly true that physicians, by virtue of their stature in the community, are perceived as leaders and often chosen as leaders for various civic endeavors, physicians have therefore become comfortable with assuming leadership roles. However, being a leader does not often translate into being an effective manager of a process or a system. In fact, the literature defines distinct differences between leadership skills and management skills. The attributes of effective leaders will be discussed later in this article. Let's now examine and attempt to understand some inherent differences between clinicians and managers. The following paragraphs summarize this dual role concept and are attributed to Mr. Kurtz's excellent work. First of all, physicians tend to be doers; managers must be designers. Physicians spend their time doing things to or for patients, such as examinations and procedures. Direct action by the physician is the only vehicle for recompense. Managers, on the other hand, must design the systems in which the "doers" can best accomplish their work. In fact, the work usually delegated to staff personnel, which is what separates the manaqer from the worker. ~eco
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are forced to accept delayed gratification. Although it is certainly true that the educational process to become a physician is inordinately long and requires some sense of delayed gratification, it is also a predetermined, highly structured system in which the day-to-day rewards and disappointments come in a rapid-fire progression. Physicians frequently see their work bear fruit within hours, days, or weeks, such as a patient response to medication or a surgical procedure. Managers must have the patience to guide organizations through long-range goals and objectives and have the foresight to develop strategies that will have far-reaching impact. Therefore, a manager may not see the result of his work for years. Fourth, physicians value independence and autonomy, whereas managers strongly value participation and collaboration. Physicians demonstrate a very low need for inclusion and resist allowing others to influence them. These actions perhaps result from the old medical school and residency construct, "see one, do one, teach one," which was a relatively efficient way to master a huge volume of techniques and talents in a short period of time, but may have falsely given physicians a sense of immediate competency. Physicians spend a great deal of time and energy protecting this autonomy and independence. In order to ensure quality and commitment in decision making and problem solving, managers recognize the need to involve others in this process, fostering participation and consensus. Fifth, physicians tend to be most comfortable and most successful in one-to-one encounters, whereas managers spend much of their time in group inteuaction. Physicians prefer to deal with others on an individual basis, such as doctor-patient, doctor-nurse, doctor-doctor, possibly because of the traditional medical training process, which orients physicians to the private doctor-patient relationship. Although this behavior is successful for the medical practitioner, it certainly challenges his or her effectiveness as a physician manager because a manager tackles problem solving in groups. It has been estimated that 73% of a manager's time is spent in meetings and group settings. Sixth, physicians advocate for the patient, whereas managers primarily function as advocates of the organization. Physicians have been traditionally taught that "if the patient needs, the patient gets." Physicians occasionally must make decisions based on isolated, unique, and specific facts of a certain case, whereas managers are expected to make decisions that are consistent with organizational policy and norms. This concept of predictability carries extreme weight in evaluating effective managerial behavior; otherwise, the manager would be managing by exception, resulting in organizational chaos. On the other hand, physician advocacy for the individual situation explains why resolving conflict in medical staff meetings is nearly impossible; each physician truly believes he or she is uniquely and inherently "right" in their position, and they can recall a case (one of their own) to prove it. Seventh, the advocacy orientation issue is further polarized by each group's primary mode of identification. Physicians will tend to identify
with their professional group, and more specifically, with their specialist peers. The next level of identification would most often be as a member of a certain medical community (i.e., TLC hospital medical staff). If asked by a stranger, "who are you," a clinician would almost always first reply, "a physician," and if questioned further, would say, "ophthalmologist," and finally, "member of TLC hospital staff" or "best care clinic group." Physicians generally do not relate to the concept of "employment" or "unemployment" (although this is rapidly changing). Because of this orientation, the physician sees the organization as simply a place that provides the environment to practice medicine. The manager's identity, however, is totally dependent on employment or unemployment by an organization. Without an organization to manage, the manager can no longer be identified as such. When asked the same question, "who are you," the manager will respond, for example, that he or she is the "vice president of financial services for TLC hospital." The manager perceives himself or herself as "belonging" to TLC hospital, and the organization provides for and promotes this identification. The differences between physicians and managers in Table 1 are only a few in a longer list of practical and philosophical differences that Michael E. Kurtz so eloquently describes. They are significant, however, and tend to create the greatest degree of role conflict for the physician manager. It is critically important to recognize that each set of behaviors and characteristics is necessary for satisfactory performance in the specific role demand (i.e., clinician or manager). The physician who chooses to enter into management, however, will most often find himself or herself bridging the gap between the two. Most physician managers attempt to continue some clinical involvement to at least maintain, if not enhance, clinical skills. To completely leave the practice of medicine means turning one's back on the primary identification group and giving up membership in an exclusive and elite professional "club." Leaving the practice of medicine can be a psychologically wrenching experience; however, filling in this potential void, there are now two dynamic and growing professional physician associations that physician leaders may identify with. The American Table 1. DUAL ROLE OF PHYSICIAN MANAGERS Phvsicians
Managers
Tend to be doers Reactive ueslre lmmealate results Value independence and autonomy One-to-one encounters Advocates for the patient Identify with professional group
Must be designers Proactive Hccepr aeiayea grariiicarion Value participation and collaboration Group interaction Advocates of the organization Identify by employment or by organization
Data from Kurtz ME: The dual role dilemma. In Curry W (ed): New Leadership in Health Care Management: The Physician Executive. Tampa, American College of Physician Executives, 1988, pp 65-73; with permission.
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Medical Directors Association* specifically represents medical directors and attending physicians involved in long-term care (skilled nursing facilities, subacute care, CCRCs, or assisted living). The American College of Physician Executivest seeks to address the needs and issues of any medical director or physician executive, whether involved with hospitals, physician clinic groups, insurance companies, or HMOs, for example. Both of these organizations have certificate programs available to physicians that require continuing education building on the principles of administrative or organizational medicine. The traditional adversarial positioning of medicine versus administration is being challenged at many levels, and new roles are being created that foster collaboration and cooperation. Involvement of the physician manager may be the single most critical element in this process for today's proactive healthcare organization. Dr. Leland R. Kaiser, a futurist and general systems theorist, is a management consultant specializing in physician development, team functioning, strategic planning, and organizational culture building. In a keynote address to the annual meeting of the American Academy of Otolaryngology in 1991, Dr. Kaiser said I discovered a long time ago that if I made a forecast and went and fulfilled it, my forecasting accuracy was astonishingly high. Remember, the future is not something you predict, the future is something you do. What we need are physicians who are selffulfilling prophets with a vision of healthcare in this country, and who enable their local communities to begin realizing the vision. The reformation of the United States healthcare system is not from the top down; it is from the bottom
It is important to consider what the future holds. Dr. Kaiser offers contrasts between the old paradigm and the new paradigm in Table 2. GENERAL PRINCIPLES
Armed with a basic knowledge of the physician manager's dual role, as well as the thoughts of futurists on the new paradigms in health care delivery for the remainder of the 1990s and into the 21st century, one must understand three critical concepts of functioning as a medical director in a large organization. The first is the concept of constituencies. Constituencies
A constituency is one or more persons who can affect results, cause changes strategies, withhold or limit needed resources, or generally *American Medical Directors Association, 10480 Little Patuxent Parkway, Suite 760, Columbia, MD 21044; (410) 740-9743. tAmerican College of Physician Executives, 4890 West Kennedy Boulevard, Suite 200, Tampa, FL 33609-2575, 813/287-2000.
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Table 2. CONTRASTING PARADIGMS Old Paradigm
New Paradigm
Institutional resources Historical Status quo Physician centered Disease as pathology Coming to us Hospital with walls Treatment Licensure Functional architecture Scientific method High tech Separative Left brained Federal responsibility Middle years
Community resources Futuristic Innovative Patient centered Disease as transformation Going to them Hospital without walls Prevention Competence Healing architecture Intuitive method High touch Integrative Right brained Local responsibility Early and late years
Adapted from Kaiser LR: Presentation at Physician in Management Ill Seminar. Monterey, CA, American College of Physician Executives, September 1993; with permission.
cause trouble. Intent is irrelevant. The fact that they can is important. Everyone, regardless of rank in the organization, has multiple constituencies. The successful CEO (and corporate medical director) will be acutely aware of this. More CEOs are "unhorsed" for defining their constituencies too narrowly than for bottom line deficiencies6 It was noted previously that in a large organization, a new corporate medical director (Vice President of Medical Affairs or Vice President of Professional Services) will be but one of a dozen or more other vice presidents, not to mention senior vice presidents or executive vice presidents. Each of those individuals will head up a constituency of personnel that, in one way or another, will affect your successful functioning within the organization. It would be wise for the new corporate medical director to make an effort not only to form relationships with these individuals but, perhaps more importantly, to clearly understand how each of his or her constituencies fits into the corporate puzzle. Obviously, today's enlightened corporations have a vision that is supplemented by a mission, a philosophy or values, and goals. From those broad statements, each organization will have a strategic plan to accomplish its mission and goals. If the corporate medical director is new, it is imperative that he or she clearly understands the intricacies of the organization's goals and how each of the aforementioned constituencies interrelate to achieve those goals. Understanding the system is paramount to getting things done. If the corporate medical director brings new goals and strategies to the organization, it is important that time be taken to appropriately integrate those goals into the belief system of the organization, or at the very least, to try to determine if those new goals are in any way diametrically opposed to the goals of other constituencies in the organi-
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zation. This time-consuming process is usually not done in a month; 6 months to 1 year or more is more accurate. The larger the organization, the more complicated and convoluted are the constituencies. If even a portion of the organization's goals are consistent with the goals of the new corporate medical director, however, the new medical director (and his or her constituency) may be just the vehicle for the organization to successfully grow and prosper. In general, the author believes it is this latter scenario that is motivating corporations to look very carefully and favorably at the role of corporate medical director. Leadership
The second concept is leadership. Volumes of management literature have been written on this topic. Additionally, an equal number of volumes have been written to compare and contrast the characteristics of leaders and managers. The following paragraph attempts to summarize the salient points of what superior leaders Leaders are extremely effective at listening and coaching. They are very approachable and yet often initiate contact with others. Their listening skills are enhanced by empathy and insight. Leaders are good at setting goals, often unwritten, but always clear, and they communicate these goals effectively to all personnel. Leaders also delegate effectively using the chain of command. They are good problem solvers and engage in critical thinking. When solving problems, these individuals have a knack for identifying resources, gathering information (and recognizing discrepancies), and arriving at solutions cooperatively with others. Leaders have a knack of handling conflict resolution in a rational and flexible manner, usually characterized by displaying self control, avoiding involvement of personal feelings, and maintaining a flexible posture at all times. Leaders are also very conscious of the feedback loop. They understand the necessity of monitoring and measuring results of an action and then providing feedback to people on their progress. Finally, leaders always look for opportunities to reward team results, which is done in an environment of open communication and actually results in effective team building. Negotiation
The third critical concept is a basic understanding of negotiation. In the book Getting to Yes, Roger Fisher and William Ury list four critical components of effective negotiation': (1) Separate the people from the problem, which involves understanding what is substance and what is the relationship. The relationship tends to get tangled up with the problem and must always be separated so that one can deal directly with people (relationship) problems; (2) Focus on interests, not positions. Interests define the problem, and each side has multiple interests. Effective negotiation is better achieved when one realizes that behind oppos-
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ing positions often lie shared and compatible interests; (3) Invent options for mutual gain by broadening the options and searching vigorously for mutual gain. During the negotiation process, it is also helpful to invent ways of making decisions easier; (4) Insist on objective criteria. Use fair standards and fair procedures, and consider use of an outside expert or third party. Reason and be open to reason, but never yield to pressure. RESPONSIBILITIES
Having reviewed the basics on leadership skills, management skills, negotiation skills, understanding constituencies, and taking a brief look at the future health care paradigm, we are now ready to go forth into the dynamic health care industry and accomplish wondrous feats as a corporate medical director, but just exactly what does one do? Suppose dedicated office time, computer, certificates on the wall, medical and management books, personalized stationary and business cards, and secretarial assistance are available. What next? In the remainder of this article, the author highlights mostly from personal experience the major themes of responsibility likely to be encountered. First, meet and greet your new colleagues. Find out what their goals, agendas, and constituencies are. I cannot overemphasize the importance of building working relationships with new peers. Then, gravitate to "where the moments of truth occur," the point at which there is patient-caregiver interaction. If this interaction occurs in the same building as your office, you are in luck; however, with today's horizontally and vertically integrated corporations, it may be necessary to get out on the road and visit numerous facilities. Learn about the business and all of its relevant parts while utilizing those management and leadership skills previously discussed. Read and become an expert in the components of law, regulation, and policy affecting your domain. Because you are a physician with a new title in the organization, you will no doubt be granted some modicum of respect and salutation that should last for several months; however, eventually the organization will begin to expect something from you. Next, determine who your primary constituency is. Ninety-nine percent of the time it will be the physician community. In elementary terms, others in the organization may perceive that the only reason you have been hired is to deal with "the doctors," which of course is true enough but potentially presents your first dilemma. Doctors may be difficult to deal with. Therefore, you need to figure out who they are, where they are, and determine the most effective communication tools available to reach out and relate to them. By such contact, you may believe that you give your physician colleagues direction and guidance, but they may not be receptive. Actually, by utilizing the knowledge gleaned from Kurtz7 and recognizing that physicians primarily identify with a professional group, you prepare to act upon the following executive insight: It would be advantageous to have your newfound constitu-
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ency (physicians with supposedly similar interests) affiliated with a professional association that educates and fosters those same principles. This part is easy if you are a long-term care corporate medical director desiring to build the foundation for a successful physician relations program with your facility-based medical directors; you can sponsor their membership in the American Medical Directors Association. The physicians in your constituency will automatically receive journals and newsletters and an opportunity to attend educational seminars whose message should be consistent with yours. The professional association will dictate policy and develop position statements and guidelines that you may support, which will have substantially more impact in changing behavior than you could ever personally accomplish. Next, communicate, communicate, communicate. Visit in person, if possible, phone if you cannot, and always (at least initially) follow up visits and phone calls with letters that are copied to others appropriately and strategically. As mentioned previously, others in the organization will quickly perceive your primary role as physician liaison. Therefore, you will likely become inundated with requests to intervene in conflicts and grievances that in some way involve physicians. These grievances could be physician-physician conflict, nurse-physician conflict, administratorphysician conflict, family member-physician conflict, or medical director-attending physician conflict to name a few. Intervening in these conflicts will, no doubt, present some of the more challenging aspects of your new position. Undaunted, however, you reach back into your knowledge base of leadership skills, including effective listening, flexibility, self control, avoidance of involving personal feelings, combine that with a few of the negotiation skills discussed, and jump into the fray. This can be a very satisfying part of your day as you assist in resolving these conflicts to the benefit of all parties, and most importantly, the patient. Third, begin to hone your problem-solving skills. Don't try to tackle many problems, but prioritize two or three and develop a broad-based coalition to solve them, visibly making a difference in the organization. Examples might include addressing a patient care issue as identified by satisfaction surveys or developing a practice guideline to control variability in conducting a high liability medical procedure or treatment of a high-risk patient category. Remember that although you are tackling your priority issues, you should be cognizant of how your actions will affect other constituencies. Next, get involved in the organization's quality improvement process. Long-term care has historically been mired in an adversarial and punitive regulatory environment. The continuity and consistency of this very subjective, inspection-based regulation has been suspect. On too many occasions, different surveyors offer conflicting views on the same issue, creating a vicious cycle in which facility staff get caught up in "temporary fixes" that never address the root cause of a problem. These "temporary fixes" have, in some cases, resulted in facility staff believing that they are trapped in a "no win" situation and that the quality
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assurance process is simply paper compliance to keep surveyors off their back. This result is tremendously unfortunate because a good quality improvement process can be the cornerstone for happy and satisfied customers (patients) as well as employees. What can the physician bring to the situation? More detailed knowledge and the objectivity of a classical scientist. Long-term care has been lacking an objective database, and most of the available literature is based on very small sample sizes. Even physicians extensively involved in caring for the nursing facility population will admit to a substantial amount of trial and error in dealing with the very complex psychosociall functional, and medical issues besieging their frail elderly patients. There is a substantial need to develop accurate databases to promote outcomes management in long-term care. Physicians, as we have previously discussed, are schooled in the scientific method, have a knack for detail, are "doers," and therefore, should positively augment the process of developing key indicatorss and establishing benchmarks for care. The quality improvement process is an extremely important subject that is discussed in detail in another article in this issue. Today's physician executive has a key role to play in the management of clinical information. Most health care organizations have an information systems (IS) department that reports to or is part of the finance department. In the traditional structure, this arrangement seemed quite prudent because historically, most of the information being managed was financial (e.g., accounts payable, accounts receivable, and payroll). The successful health care organization of tomorrow, however, must rapidly shift its focus to computerizing the patient record and developing a system of clinical information management that allows the organization's providers of care (doctors, nurses, and therapists) to evaluate patient outcomes and to determine what works well and what doesn't, thereby eliminating the rather large variability in practice patterns that currently exist and ultimately improving the delivery of patient care. As mentioned in the previous paragraph, outcomes management depends on the development of an accurate clinical database. Once again, it is the physician executive who is best suited to lead this effort, not the financial gurus who have traditionally dictated the priorities for information management. Long-term care or chronic care patients are rapidly finding center stage in most bioethics discussions, a trend that will likely not abate. Such issues as quality of life, futility, and rationing of care will plunge the long-term care medical director into the spotlight as health care providers, payors, and the courts s r a ~ v l ewith this subi~rt. Additionally, the corporate medical director should take an active role in the organization's risk management and legal affairs departments. As the acuity level of today's long-term care facility patients has escalated and the industry has moved from providing a custodial service to a more sophisticated health care service, the litigation generated is becoming more medically intensive. Old beliefs are being questioned, and new studies are constantly reshaping the way we think about
Table 3. TOP TWENTY NURSING FACILITY CHAINS
NamelChief Executive Officer
Addressllelephone
Total Nursing Facility Beds
P.O. Box 3324 Fort Smith, AR 72913 5011452-6712 1148 Broadway Plaza The Hillhaven Corp. Tacoma, WA 98402 Bruce L. Busby 2061572-4901 10770 Columbia Pike Manor Healthcare Corp. Silver Spring, MD 20901 Steward Bainum, Jr. 3011593-9600 15415 Katy Fwy., Ste. 800 Living Centers of America* Houston, TX 77094 Edward L. Kuntz 7131578-4600 3570 Keith St., N.W. Life Care Centers of America, Inc Cleveland, TN 37312 Forrest Preston 6151472-9585 The Evangelical Lutheran Good Samaritan Society 1000 West Avenue North P.O. Box 5038 Dr. Mark A. Jerstad Sioux Falls, SD 571 17-5038 6051336-2998 One SeaGate Health Care and Retirement Corp Toledo, OH 43604-2616 Paul A. Ormand 41 91247-5492 105 W. Michigan St. United Health, Inc. Milwaukee, WI 53203 Frederick B. Ladly 4141271-9696 148 West State St. Genesis Health Ventures, Inc. Kennett Square, PA 19348 Michael R. Walker 2151444.6350 5050 Poplar Ave., ServiceMaster Diversified Health ServiceslVHA Ste. 1800 Long Term Care Memphis, TN 38157 Jerry D. Mooney 9011767-2220 10065 Red Run Blvd. Integrated Health Services, Inc. Owings Mills, MD 21 117 Robert N. Elkins 4101998-8400 401 N. Elm St. Texas Health Enterprises & Affiliates Denton, TX 76201 Peter C. Kern 8171387.4388 300 Corporate Pointe, Ste. 400 GranCare, Inc. Culver City, CA 90230 Gene Burleson 3101645-1555 City Center, 100 Vine St. National HealthCorp L.P Murfreesboro, TN 37130 W. Andrew Adams 6151890-2020 2415 S. Volusia Ave., Ste. A4 Meadowbrook Management Co, Inc Orange City, FL 32763 Don G. Angell 9041775-2608 761 1 State Line Rd., Ste. 301 The Tutera Group Kansas City, MO 641 14 Joseph C. Tutera 8161444-0900 6001 Indian School Rd., N.E. Horizon Healthcare Corp Albuquerque, NM 871 10 Neal M. Elliott 5051881-4961 184 Shuman Blvd., Ste. 200 Evergreen Healthcare, Inc. Naperville, IL 60563 William G. Petty, Jr. 7081357-6664 P.O. Box 6159 Britthaven, Inc. Kinston, NC 28501 Robert Hill 9191523-9094 1331 Fourth St. Dr., N.W. Brian Center Mgmt. Corp Hickory, NC 28601 Donald C. Beaver 7041322-3362 Beverly Enterprises, Inc.* David R. Banks
'Have corporate medical directors. Adapted from the American Health Care Association: Provider surveys top chains. Provider 20:3537, 1994, copyright 0 American Health Care Association; with permission.
geriatric care in almost every avenue-behavior management, rehabilitation therapies, physical restraint use, prescribing of medications, exercise programs, socialization needs, and treatment of depression. The Patient Self-Determination Act, new OSHA regulations, such as those on hepatitis and tuberculosis, the Safe Medical Devices Act, The Americans with Disabilities Act, and so on, all add a new dimension to a long-term care corporation's risk management responsibilities and beg for physician input. And finally, keep your advocacy orientation patient-focused. In this regard you should be a beacon for the organization but also try to expand your identity orientation beyond your professional physician group to include the organization itself. This may pose some extraordinarily difficult mental gymnastics for most physicians. On the other hand, look to a successful career manager, such as a Vice President of Operations, for whom it is but second nature to shoulder responsibility for any one of his line employees, sometimes even those he may not personally know. Those employees (associates) are the lifeblood of the organization; therefore, support is deserved. This concept is totally foreign to physicians who would choose to identify only with other physicians as highly trained, in their same discipline, and preferably known. After 5 vears as a full-time corporate medical director, I still respond with "p6ysician" and not my Lsiness title and corporate name &hen asked what I do (the transition is obviously a slow one). Nevertheless, I am beginning to understand the extraordinary benefits derived when an organization's leaders wholeheartedly support their coworkers. It speaks very positively about an organization's culture and confidence in its associates and makes it a desirable place to work. If you have an interest in pursu~nga career as a physician executive and perhaps working as a corporate medical director for a long-term care organization, Table 3 lists the 20 largest long-term care corporations in the country. Good luck. References 1. Fisher R, Ury W: Getting to Yes. New York, Penguin Books USA Inc., 1991 2. Gilbreath, RD: Forward Thinking: The Pragmatist's Guide to Today's Business Trends. New York, McGraw-Hill Books, 1987, p xii 3. Kaiser LR: Designers of the future. Otolaryngology: Head and Neck Surgery. April, 1992, 106:4 4. Kaiser LR: Physician in Management I11 seminar [presentation]. Monterey, CA, Ameriz L: ..... C ,... 1 .....3 1 2 1 - 1""2 "^..CL"IILbL ,.?? ,..-.. V,.'73L.,.:,.:.y. I 5. Kennedy MM: Physician in Management I seminar [presentation]. Scottsdale, AZ, American College of Physician Executives, April 23-27, 1990 6. Kennedy MM: Kennedy's Career Strategist, September, 1988 7. Kurtz ME: The dual role dilemma. In Curry W (ed): New Leadership in Health Care Management: The Physician Executive. Tampa, FL, American College of Physician Executives, 1988, pp 65-73 8. Levinson SA (ed): Medical Direction in Long-Term Care: A Guidebook for the Future. Durham, NC, Carolina Academic Press, 1993, pp 551-553 C U L L
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9. McDowell T, Brown H: Integrated delivery systems. Transitions. 1:9-11, 1994 10. Shieber G, Poullier J, Greenwald L: Health spending, delivery, and outcomes in OECD countries. Health Affairs, 120-129, 1993
Address vepsint requests to Keith Krein, M D Living Centers of America 15415 Katy Freeway, Suite 800 Houston, TX 77094
0749-O69O/95 $0.00
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THE CORPORATE MEDICAL DIRECTOR Keith Krein, MD
"Something unusual, puzzling and powerful, is about, and it shows no signs of stopping or even abating its influence. It is the phenomenon of change, and it is gaining on us."2 ROBERT D. GILBREATH
This article conceptually examines the role of the corporate medical director in three broad categories: (1) what is going on in health care today, and more specifically, what is going on within health care corporations that would suggest a need for this article, (2) what are the attributes of a successful corporate medical director, and (3) what would be the major themes composing the corporate medical director's primary responsibilities. EVOLUTION OF HEALTH CARE DELIVERY
Dynamic changes are occurring in health care throughout the world. Whether one is for, against, or indifferent to such changes is immaterial. If one is involved in health care, the paradigm shifts occurring today will significantly affect his or her life. The major change agent is a shift in focus from providers of care to purchasers of care. The purchasers are looking at controlled costs, increased access, and documented quality. All reporting health care systems share the same delivery problems, external (ever-rising costs) and internal (variable and inefficient care). The costs are partially driven by uncontrollable factors, such as the worldwide aging of the population, technologic advances, and profesFrom the Living Centers of America, Houston, Texas
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sional liability. In 1991, per capita health spending in the United States exceeded that of Canada by approximately 509'0, Germany and France by 75%, Sweden, Finland, Italy, and Australia by 10O0/0,Japan by 120%, the United Kingdom by 175%, and Spain and Ireland by 240%.1° Undoubtedly, the health care industry in the United States was very good, but its costs significantly outpaced other developed nations. In late 1992 and 1993, however, some amazing headlines began to capture the business pages of the nation's papers. The rate of increase in the medical care component of the Consumer Price Index actually began declining, reversing years of relentless increase. The political strategies of the early 1990s focused the nation's eyes on health care, specifically its cost and availability. Business entities saw this situation as an opportunity to create more efficient ways of providing health care services. Hospital occupancy rates steadily declined as alternative, more efficient sites of care developed. Specialists who performed large numbers of medical procedures or who billed for them at very expensive rates were also targets for innovation. Even the need for such large numbers of specialists was questioned because specialists represented a far larger proportion of physicians in the United States than in other countries whose health status appeared equivalent. The fee-for-services paradigm had started to change. Therefore, there are three realities for tomorrow's health care delivery system. First, controlling costs will drive the system. Because the aging world population is recognized as one of the uncontrollable factors driving cost, this issue becomes of paramount importance for those involved in geriatrics and long-term care. There are controllable factors, however, that drive costs as well. Those that claim quality health care and cost effectiveness are mutually exclusive should study the works of Deming, Crosby, and Juran. There is ample evidence to suggest that opportunities abound to reduce waste and rework and eliminate variability in the health care system. So what drives the controllable costs? Thousands of varied components drive costs from high-tech to hightouch, but the particulars are inevitably traced back to the physician's assessment and plan of care, including diagnostic tests and therapies-strong argument for physician involvement in managing the process. Second, alternative sites of service and niche strategies for care will abound. Over the last decade, an array of services has been carved from the hospital domain. Ambulatory surgery centers, home infusion companies, rehabilitation centers, and respiratory hospitals are just a FAT AS hnsnitalq rontim~eto evolve as vlaces of highlv technologic diagnostic interventions and invasive procedures, much of the preparation for and recovery from such experiences will occur elsewhere. Today, included in the growth and development stages of the geriatric health care service life cycle are Medicare-skilled nursing, specialized units for Alzheimer's programming, adult day care, assisted living (even dementia-specific assisted living), and subacute care focusing on rehabilitation therapies for orthopedic, stroke, brain and spinal cord injury, amputee,
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arthritis, and pain management patients. Another branch of subacute care focuses on more medically complex patients, such as those requiring pulmonary care, wound management, complex intravenous administration, postsurgical care, and cancer to name just a few. The list grows as hospital stays shrink. The involvement of corporations in this alternative-site-of-care phenomenon becomes manifest in the concept of Integrated Delivery Systems (IDS).9Through the 1970s and 1980s, health care corporations took advantage of horizontal integration as an effective strategy for controlling costs. For example, many health care organizations realized that growth through carefully planned acquisitions and mergers could keep fixed overhead costs in check or even reduced. Overhead reduction occurred as efficient centralized departments, handling such necessary functions as payroll, accounts receivable, accounts payable, and purchasing, absorbed the extra work into their existing systems while allocating overhead among a greater number of facilities, thereby reducing the per patient cost. Likewise, the larger the number of employees or patients, the more power was wielded at the bargaining table to negotiate everything from food to equipment and supply purchases. Today, vertical integration strategies are being developed, such one corporation owning or managing care at multiple acuity levels (acute, subacute, long-term care, assisted living, or home health). In this strategy, patients can be moved through the continuum of care as necessary, avoiding the dilemma of a patient being needlessly maintained in a high-cost center when a lower-cost center would be equally appropriate. Theoretically, in a seamless, vertically integrated system, patients would be readily transferred from one site to the next, as dictated by their medical needs. The complexities of such a system obviously require physician involvement and expertise (supervision). Third, an emphasis is placed on primary care physicians to appropriately refer patients through the emerging maze called the health care continuum and is gaining momentum. Obviously, professional liability issues must be addressed in this changing scenario. There will be an increasing need for competent physicians with business acumen and management and leadership skills to be liaisons between the purchasers and providers of health care, such as between the medical staff and board of directors. A philosopher once said, "Control your own destiny or someone else will!" This quote is apropos for today's physician community, and it leads to the premise that physicians and health care institutions that prepare proactively will thrive; others will not. ATTRIBUTES OF A SUCCESSFUL MEDICAL DIRECTOR
Presently, there is a growing place in health care for physicians with leadership and management skills (e.g., corporate medical director or physician executive). Before discussing the responsibilities such a
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position would entail, there are some attributes that would engender success. In this regard, it is imperative to compare and contrast the dual role of the physician as clinician and the physician as manager. Michael E. Kurtz, MS writes persuasively and with extraordinary insight regardA thorough understanding of this subject matter is ing this dual vital to the success of any physician contemplating an executive role in a health care corporation. Today's corporate medical director also receives a business title such as Vice President of Medical Affairs or Vice President of Professional Services. In a large corporation, this means that the physician will be one of a dozen or more vice presidents. It is also quite likely that all the other vice presidents have had extensive business, financial, and managerial training, including postgraduate degrees. In order to effectively contribute to and communicate with these organizational peers, physicians must understand how their previous "world" (education, training, peers) differs from that of their newfound business associates. Physicians are significantly influenced by the values and norms of the world of medicine. The most formative years of their professional lives are spent in this "rite of passage" that shapes their view of the world as practicing physicians. These learned behaviors are successful for them and necessary if they are to achieve the desired outcomes and acceptance of their physician colleagues and peers; however, these same behaviors and characteristics can pose problems for the new medical director. Although it is certainly true that physicians, by virtue of their stature in the community, are perceived as leaders and often chosen as leaders for various civic endeavors, physicians have therefore become comfortable with assuming leadership roles. However, being a leader does not often translate into being an effective manager of a process or a system. In fact, the literature defines distinct differences between leadership skills and management skills. The attributes of effective leaders will be discussed later in this article. Let's now examine and attempt to understand some inherent differences between clinicians and managers. The following paragraphs summarize this dual role concept and are attributed to Mr. Kurtz's excellent work. First of all, physicians tend to be doers; managers must be designers. Physicians spend their time doing things to or for patients, such as examinations and procedures. Direct action by the physician is the only vehicle for recompense. Managers, on the other hand, must design the systems in which the "doers" can best accomplish their work. In fact, the work usually delegated to staff personnel, which is what separates the manaqer from the worker. ~eco
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are forced to accept delayed gratification. Although it is certainly true that the educational process to become a physician is inordinately long and requires some sense of delayed gratification, it is also a predetermined, highly structured system in which the day-to-day rewards and disappointments come in a rapid-fire progression. Physicians frequently see their work bear fruit within hours, days, or weeks, such as a patient response to medication or a surgical procedure. Managers must have the patience to guide organizations through long-range goals and objectives and have the foresight to develop strategies that will have far-reaching impact. Therefore, a manager may not see the result of his work for years. Fourth, physicians value independence and autonomy, whereas managers strongly value participation and collaboration. Physicians demonstrate a very low need for inclusion and resist allowing others to influence them. These actions perhaps result from the old medical school and residency construct, "see one, do one, teach one," which was a relatively efficient way to master a huge volume of techniques and talents in a short period of time, but may have falsely given physicians a sense of immediate competency. Physicians spend a great deal of time and energy protecting this autonomy and independence. In order to ensure quality and commitment in decision making and problem solving, managers recognize the need to involve others in this process, fostering participation and consensus. Fifth, physicians tend to be most comfortable and most successful in one-to-one encounters, whereas managers spend much of their time in group inteuaction. Physicians prefer to deal with others on an individual basis, such as doctor-patient, doctor-nurse, doctor-doctor, possibly because of the traditional medical training process, which orients physicians to the private doctor-patient relationship. Although this behavior is successful for the medical practitioner, it certainly challenges his or her effectiveness as a physician manager because a manager tackles problem solving in groups. It has been estimated that 73% of a manager's time is spent in meetings and group settings. Sixth, physicians advocate for the patient, whereas managers primarily function as advocates of the organization. Physicians have been traditionally taught that "if the patient needs, the patient gets." Physicians occasionally must make decisions based on isolated, unique, and specific facts of a certain case, whereas managers are expected to make decisions that are consistent with organizational policy and norms. This concept of predictability carries extreme weight in evaluating effective managerial behavior; otherwise, the manager would be managing by exception, resulting in organizational chaos. On the other hand, physician advocacy for the individual situation explains why resolving conflict in medical staff meetings is nearly impossible; each physician truly believes he or she is uniquely and inherently "right" in their position, and they can recall a case (one of their own) to prove it. Seventh, the advocacy orientation issue is further polarized by each group's primary mode of identification. Physicians will tend to identify
with their professional group, and more specifically, with their specialist peers. The next level of identification would most often be as a member of a certain medical community (i.e., TLC hospital medical staff). If asked by a stranger, "who are you," a clinician would almost always first reply, "a physician," and if questioned further, would say, "ophthalmologist," and finally, "member of TLC hospital staff" or "best care clinic group." Physicians generally do not relate to the concept of "employment" or "unemployment" (although this is rapidly changing). Because of this orientation, the physician sees the organization as simply a place that provides the environment to practice medicine. The manager's identity, however, is totally dependent on employment or unemployment by an organization. Without an organization to manage, the manager can no longer be identified as such. When asked the same question, "who are you," the manager will respond, for example, that he or she is the "vice president of financial services for TLC hospital." The manager perceives himself or herself as "belonging" to TLC hospital, and the organization provides for and promotes this identification. The differences between physicians and managers in Table 1 are only a few in a longer list of practical and philosophical differences that Michael E. Kurtz so eloquently describes. They are significant, however, and tend to create the greatest degree of role conflict for the physician manager. It is critically important to recognize that each set of behaviors and characteristics is necessary for satisfactory performance in the specific role demand (i.e., clinician or manager). The physician who chooses to enter into management, however, will most often find himself or herself bridging the gap between the two. Most physician managers attempt to continue some clinical involvement to at least maintain, if not enhance, clinical skills. To completely leave the practice of medicine means turning one's back on the primary identification group and giving up membership in an exclusive and elite professional "club." Leaving the practice of medicine can be a psychologically wrenching experience; however, filling in this potential void, there are now two dynamic and growing professional physician associations that physician leaders may identify with. The American Table 1. DUAL ROLE OF PHYSICIAN MANAGERS Phvsicians
Managers
Tend to be doers Reactive ueslre lmmealate results Value independence and autonomy One-to-one encounters Advocates for the patient Identify with professional group
Must be designers Proactive Hccepr aeiayea grariiicarion Value participation and collaboration Group interaction Advocates of the organization Identify by employment or by organization
Data from Kurtz ME: The dual role dilemma. In Curry W (ed): New Leadership in Health Care Management: The Physician Executive. Tampa, American College of Physician Executives, 1988, pp 65-73; with permission.
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Medical Directors Association* specifically represents medical directors and attending physicians involved in long-term care (skilled nursing facilities, subacute care, CCRCs, or assisted living). The American College of Physician Executivest seeks to address the needs and issues of any medical director or physician executive, whether involved with hospitals, physician clinic groups, insurance companies, or HMOs, for example. Both of these organizations have certificate programs available to physicians that require continuing education building on the principles of administrative or organizational medicine. The traditional adversarial positioning of medicine versus administration is being challenged at many levels, and new roles are being created that foster collaboration and cooperation. Involvement of the physician manager may be the single most critical element in this process for today's proactive healthcare organization. Dr. Leland R. Kaiser, a futurist and general systems theorist, is a management consultant specializing in physician development, team functioning, strategic planning, and organizational culture building. In a keynote address to the annual meeting of the American Academy of Otolaryngology in 1991, Dr. Kaiser said I discovered a long time ago that if I made a forecast and went and fulfilled it, my forecasting accuracy was astonishingly high. Remember, the future is not something you predict, the future is something you do. What we need are physicians who are selffulfilling prophets with a vision of healthcare in this country, and who enable their local communities to begin realizing the vision. The reformation of the United States healthcare system is not from the top down; it is from the bottom
It is important to consider what the future holds. Dr. Kaiser offers contrasts between the old paradigm and the new paradigm in Table 2. GENERAL PRINCIPLES
Armed with a basic knowledge of the physician manager's dual role, as well as the thoughts of futurists on the new paradigms in health care delivery for the remainder of the 1990s and into the 21st century, one must understand three critical concepts of functioning as a medical director in a large organization. The first is the concept of constituencies. Constituencies
A constituency is one or more persons who can affect results, cause changes strategies, withhold or limit needed resources, or generally *American Medical Directors Association, 10480 Little Patuxent Parkway, Suite 760, Columbia, MD 21044; (410) 740-9743. tAmerican College of Physician Executives, 4890 West Kennedy Boulevard, Suite 200, Tampa, FL 33609-2575, 813/287-2000.
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Table 2. CONTRASTING PARADIGMS Old Paradigm
New Paradigm
Institutional resources Historical Status quo Physician centered Disease as pathology Coming to us Hospital with walls Treatment Licensure Functional architecture Scientific method High tech Separative Left brained Federal responsibility Middle years
Community resources Futuristic Innovative Patient centered Disease as transformation Going to them Hospital without walls Prevention Competence Healing architecture Intuitive method High touch Integrative Right brained Local responsibility Early and late years
Adapted from Kaiser LR: Presentation at Physician in Management Ill Seminar. Monterey, CA, American College of Physician Executives, September 1993; with permission.
cause trouble. Intent is irrelevant. The fact that they can is important. Everyone, regardless of rank in the organization, has multiple constituencies. The successful CEO (and corporate medical director) will be acutely aware of this. More CEOs are "unhorsed" for defining their constituencies too narrowly than for bottom line deficiencies6 It was noted previously that in a large organization, a new corporate medical director (Vice President of Medical Affairs or Vice President of Professional Services) will be but one of a dozen or more other vice presidents, not to mention senior vice presidents or executive vice presidents. Each of those individuals will head up a constituency of personnel that, in one way or another, will affect your successful functioning within the organization. It would be wise for the new corporate medical director to make an effort not only to form relationships with these individuals but, perhaps more importantly, to clearly understand how each of his or her constituencies fits into the corporate puzzle. Obviously, today's enlightened corporations have a vision that is supplemented by a mission, a philosophy or values, and goals. From those broad statements, each organization will have a strategic plan to accomplish its mission and goals. If the corporate medical director is new, it is imperative that he or she clearly understands the intricacies of the organization's goals and how each of the aforementioned constituencies interrelate to achieve those goals. Understanding the system is paramount to getting things done. If the corporate medical director brings new goals and strategies to the organization, it is important that time be taken to appropriately integrate those goals into the belief system of the organization, or at the very least, to try to determine if those new goals are in any way diametrically opposed to the goals of other constituencies in the organi-
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zation. This time-consuming process is usually not done in a month; 6 months to 1 year or more is more accurate. The larger the organization, the more complicated and convoluted are the constituencies. If even a portion of the organization's goals are consistent with the goals of the new corporate medical director, however, the new medical director (and his or her constituency) may be just the vehicle for the organization to successfully grow and prosper. In general, the author believes it is this latter scenario that is motivating corporations to look very carefully and favorably at the role of corporate medical director. Leadership
The second concept is leadership. Volumes of management literature have been written on this topic. Additionally, an equal number of volumes have been written to compare and contrast the characteristics of leaders and managers. The following paragraph attempts to summarize the salient points of what superior leaders Leaders are extremely effective at listening and coaching. They are very approachable and yet often initiate contact with others. Their listening skills are enhanced by empathy and insight. Leaders are good at setting goals, often unwritten, but always clear, and they communicate these goals effectively to all personnel. Leaders also delegate effectively using the chain of command. They are good problem solvers and engage in critical thinking. When solving problems, these individuals have a knack for identifying resources, gathering information (and recognizing discrepancies), and arriving at solutions cooperatively with others. Leaders have a knack of handling conflict resolution in a rational and flexible manner, usually characterized by displaying self control, avoiding involvement of personal feelings, and maintaining a flexible posture at all times. Leaders are also very conscious of the feedback loop. They understand the necessity of monitoring and measuring results of an action and then providing feedback to people on their progress. Finally, leaders always look for opportunities to reward team results, which is done in an environment of open communication and actually results in effective team building. Negotiation
The third critical concept is a basic understanding of negotiation. In the book Getting to Yes, Roger Fisher and William Ury list four critical components of effective negotiation': (1) Separate the people from the problem, which involves understanding what is substance and what is the relationship. The relationship tends to get tangled up with the problem and must always be separated so that one can deal directly with people (relationship) problems; (2) Focus on interests, not positions. Interests define the problem, and each side has multiple interests. Effective negotiation is better achieved when one realizes that behind oppos-
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ing positions often lie shared and compatible interests; (3) Invent options for mutual gain by broadening the options and searching vigorously for mutual gain. During the negotiation process, it is also helpful to invent ways of making decisions easier; (4) Insist on objective criteria. Use fair standards and fair procedures, and consider use of an outside expert or third party. Reason and be open to reason, but never yield to pressure. RESPONSIBILITIES
Having reviewed the basics on leadership skills, management skills, negotiation skills, understanding constituencies, and taking a brief look at the future health care paradigm, we are now ready to go forth into the dynamic health care industry and accomplish wondrous feats as a corporate medical director, but just exactly what does one do? Suppose dedicated office time, computer, certificates on the wall, medical and management books, personalized stationary and business cards, and secretarial assistance are available. What next? In the remainder of this article, the author highlights mostly from personal experience the major themes of responsibility likely to be encountered. First, meet and greet your new colleagues. Find out what their goals, agendas, and constituencies are. I cannot overemphasize the importance of building working relationships with new peers. Then, gravitate to "where the moments of truth occur," the point at which there is patient-caregiver interaction. If this interaction occurs in the same building as your office, you are in luck; however, with today's horizontally and vertically integrated corporations, it may be necessary to get out on the road and visit numerous facilities. Learn about the business and all of its relevant parts while utilizing those management and leadership skills previously discussed. Read and become an expert in the components of law, regulation, and policy affecting your domain. Because you are a physician with a new title in the organization, you will no doubt be granted some modicum of respect and salutation that should last for several months; however, eventually the organization will begin to expect something from you. Next, determine who your primary constituency is. Ninety-nine percent of the time it will be the physician community. In elementary terms, others in the organization may perceive that the only reason you have been hired is to deal with "the doctors," which of course is true enough but potentially presents your first dilemma. Doctors may be difficult to deal with. Therefore, you need to figure out who they are, where they are, and determine the most effective communication tools available to reach out and relate to them. By such contact, you may believe that you give your physician colleagues direction and guidance, but they may not be receptive. Actually, by utilizing the knowledge gleaned from Kurtz7 and recognizing that physicians primarily identify with a professional group, you prepare to act upon the following executive insight: It would be advantageous to have your newfound constitu-
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ency (physicians with supposedly similar interests) affiliated with a professional association that educates and fosters those same principles. This part is easy if you are a long-term care corporate medical director desiring to build the foundation for a successful physician relations program with your facility-based medical directors; you can sponsor their membership in the American Medical Directors Association. The physicians in your constituency will automatically receive journals and newsletters and an opportunity to attend educational seminars whose message should be consistent with yours. The professional association will dictate policy and develop position statements and guidelines that you may support, which will have substantially more impact in changing behavior than you could ever personally accomplish. Next, communicate, communicate, communicate. Visit in person, if possible, phone if you cannot, and always (at least initially) follow up visits and phone calls with letters that are copied to others appropriately and strategically. As mentioned previously, others in the organization will quickly perceive your primary role as physician liaison. Therefore, you will likely become inundated with requests to intervene in conflicts and grievances that in some way involve physicians. These grievances could be physician-physician conflict, nurse-physician conflict, administratorphysician conflict, family member-physician conflict, or medical director-attending physician conflict to name a few. Intervening in these conflicts will, no doubt, present some of the more challenging aspects of your new position. Undaunted, however, you reach back into your knowledge base of leadership skills, including effective listening, flexibility, self control, avoidance of involving personal feelings, combine that with a few of the negotiation skills discussed, and jump into the fray. This can be a very satisfying part of your day as you assist in resolving these conflicts to the benefit of all parties, and most importantly, the patient. Third, begin to hone your problem-solving skills. Don't try to tackle many problems, but prioritize two or three and develop a broad-based coalition to solve them, visibly making a difference in the organization. Examples might include addressing a patient care issue as identified by satisfaction surveys or developing a practice guideline to control variability in conducting a high liability medical procedure or treatment of a high-risk patient category. Remember that although you are tackling your priority issues, you should be cognizant of how your actions will affect other constituencies. Next, get involved in the organization's quality improvement process. Long-term care has historically been mired in an adversarial and punitive regulatory environment. The continuity and consistency of this very subjective, inspection-based regulation has been suspect. On too many occasions, different surveyors offer conflicting views on the same issue, creating a vicious cycle in which facility staff get caught up in "temporary fixes" that never address the root cause of a problem. These "temporary fixes" have, in some cases, resulted in facility staff believing that they are trapped in a "no win" situation and that the quality
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assurance process is simply paper compliance to keep surveyors off their back. This result is tremendously unfortunate because a good quality improvement process can be the cornerstone for happy and satisfied customers (patients) as well as employees. What can the physician bring to the situation? More detailed knowledge and the objectivity of a classical scientist. Long-term care has been lacking an objective database, and most of the available literature is based on very small sample sizes. Even physicians extensively involved in caring for the nursing facility population will admit to a substantial amount of trial and error in dealing with the very complex psychosociall functional, and medical issues besieging their frail elderly patients. There is a substantial need to develop accurate databases to promote outcomes management in long-term care. Physicians, as we have previously discussed, are schooled in the scientific method, have a knack for detail, are "doers," and therefore, should positively augment the process of developing key indicatorss and establishing benchmarks for care. The quality improvement process is an extremely important subject that is discussed in detail in another article in this issue. Today's physician executive has a key role to play in the management of clinical information. Most health care organizations have an information systems (IS) department that reports to or is part of the finance department. In the traditional structure, this arrangement seemed quite prudent because historically, most of the information being managed was financial (e.g., accounts payable, accounts receivable, and payroll). The successful health care organization of tomorrow, however, must rapidly shift its focus to computerizing the patient record and developing a system of clinical information management that allows the organization's providers of care (doctors, nurses, and therapists) to evaluate patient outcomes and to determine what works well and what doesn't, thereby eliminating the rather large variability in practice patterns that currently exist and ultimately improving the delivery of patient care. As mentioned in the previous paragraph, outcomes management depends on the development of an accurate clinical database. Once again, it is the physician executive who is best suited to lead this effort, not the financial gurus who have traditionally dictated the priorities for information management. Long-term care or chronic care patients are rapidly finding center stage in most bioethics discussions, a trend that will likely not abate. Such issues as quality of life, futility, and rationing of care will plunge the long-term care medical director into the spotlight as health care providers, payors, and the courts s r a ~ v l ewith this subi~rt. Additionally, the corporate medical director should take an active role in the organization's risk management and legal affairs departments. As the acuity level of today's long-term care facility patients has escalated and the industry has moved from providing a custodial service to a more sophisticated health care service, the litigation generated is becoming more medically intensive. Old beliefs are being questioned, and new studies are constantly reshaping the way we think about
Table 3. TOP TWENTY NURSING FACILITY CHAINS
NamelChief Executive Officer
Addressllelephone
Total Nursing Facility Beds
P.O. Box 3324 Fort Smith, AR 72913 5011452-6712 1148 Broadway Plaza The Hillhaven Corp. Tacoma, WA 98402 Bruce L. Busby 2061572-4901 10770 Columbia Pike Manor Healthcare Corp. Silver Spring, MD 20901 Steward Bainum, Jr. 3011593-9600 15415 Katy Fwy., Ste. 800 Living Centers of America* Houston, TX 77094 Edward L. Kuntz 7131578-4600 3570 Keith St., N.W. Life Care Centers of America, Inc Cleveland, TN 37312 Forrest Preston 6151472-9585 The Evangelical Lutheran Good Samaritan Society 1000 West Avenue North P.O. Box 5038 Dr. Mark A. Jerstad Sioux Falls, SD 571 17-5038 6051336-2998 One SeaGate Health Care and Retirement Corp Toledo, OH 43604-2616 Paul A. Ormand 41 91247-5492 105 W. Michigan St. United Health, Inc. Milwaukee, WI 53203 Frederick B. Ladly 4141271-9696 148 West State St. Genesis Health Ventures, Inc. Kennett Square, PA 19348 Michael R. Walker 2151444.6350 5050 Poplar Ave., ServiceMaster Diversified Health ServiceslVHA Ste. 1800 Long Term Care Memphis, TN 38157 Jerry D. Mooney 9011767-2220 10065 Red Run Blvd. Integrated Health Services, Inc. Owings Mills, MD 21 117 Robert N. Elkins 4101998-8400 401 N. Elm St. Texas Health Enterprises & Affiliates Denton, TX 76201 Peter C. Kern 8171387.4388 300 Corporate Pointe, Ste. 400 GranCare, Inc. Culver City, CA 90230 Gene Burleson 3101645-1555 City Center, 100 Vine St. National HealthCorp L.P Murfreesboro, TN 37130 W. Andrew Adams 6151890-2020 2415 S. Volusia Ave., Ste. A4 Meadowbrook Management Co, Inc Orange City, FL 32763 Don G. Angell 9041775-2608 761 1 State Line Rd., Ste. 301 The Tutera Group Kansas City, MO 641 14 Joseph C. Tutera 8161444-0900 6001 Indian School Rd., N.E. Horizon Healthcare Corp Albuquerque, NM 871 10 Neal M. Elliott 5051881-4961 184 Shuman Blvd., Ste. 200 Evergreen Healthcare, Inc. Naperville, IL 60563 William G. Petty, Jr. 7081357-6664 P.O. Box 6159 Britthaven, Inc. Kinston, NC 28501 Robert Hill 9191523-9094 1331 Fourth St. Dr., N.W. Brian Center Mgmt. Corp Hickory, NC 28601 Donald C. Beaver 7041322-3362 Beverly Enterprises, Inc.* David R. Banks
'Have corporate medical directors. Adapted from the American Health Care Association: Provider surveys top chains. Provider 20:3537, 1994, copyright 0 American Health Care Association; with permission.
geriatric care in almost every avenue-behavior management, rehabilitation therapies, physical restraint use, prescribing of medications, exercise programs, socialization needs, and treatment of depression. The Patient Self-Determination Act, new OSHA regulations, such as those on hepatitis and tuberculosis, the Safe Medical Devices Act, The Americans with Disabilities Act, and so on, all add a new dimension to a long-term care corporation's risk management responsibilities and beg for physician input. And finally, keep your advocacy orientation patient-focused. In this regard you should be a beacon for the organization but also try to expand your identity orientation beyond your professional physician group to include the organization itself. This may pose some extraordinarily difficult mental gymnastics for most physicians. On the other hand, look to a successful career manager, such as a Vice President of Operations, for whom it is but second nature to shoulder responsibility for any one of his line employees, sometimes even those he may not personally know. Those employees (associates) are the lifeblood of the organization; therefore, support is deserved. This concept is totally foreign to physicians who would choose to identify only with other physicians as highly trained, in their same discipline, and preferably known. After 5 vears as a full-time corporate medical director, I still respond with "p6ysician" and not my Lsiness title and corporate name &hen asked what I do (the transition is obviously a slow one). Nevertheless, I am beginning to understand the extraordinary benefits derived when an organization's leaders wholeheartedly support their coworkers. It speaks very positively about an organization's culture and confidence in its associates and makes it a desirable place to work. If you have an interest in pursu~nga career as a physician executive and perhaps working as a corporate medical director for a long-term care organization, Table 3 lists the 20 largest long-term care corporations in the country. Good luck. References 1. Fisher R, Ury W: Getting to Yes. New York, Penguin Books USA Inc., 1991 2. Gilbreath, RD: Forward Thinking: The Pragmatist's Guide to Today's Business Trends. New York, McGraw-Hill Books, 1987, p xii 3. Kaiser LR: Designers of the future. Otolaryngology: Head and Neck Surgery. April, 1992, 106:4 4. Kaiser LR: Physician in Management I11 seminar [presentation]. Monterey, CA, Ameriz L: ..... C ,... 1 .....3 1 2 1 - 1""2 "^..CL"IILbL ,.?? ,..-.. V,.'73L.,.:,.:.y. I 5. Kennedy MM: Physician in Management I seminar [presentation]. Scottsdale, AZ, American College of Physician Executives, April 23-27, 1990 6. Kennedy MM: Kennedy's Career Strategist, September, 1988 7. Kurtz ME: The dual role dilemma. In Curry W (ed): New Leadership in Health Care Management: The Physician Executive. Tampa, FL, American College of Physician Executives, 1988, pp 65-73 8. Levinson SA (ed): Medical Direction in Long-Term Care: A Guidebook for the Future. Durham, NC, Carolina Academic Press, 1993, pp 551-553 C U L L
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9. McDowell T, Brown H: Integrated delivery systems. Transitions. 1:9-11, 1994 10. Shieber G, Poullier J, Greenwald L: Health spending, delivery, and outcomes in OECD countries. Health Affairs, 120-129, 1993
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