To maintain political, governmental, staff, and patient loyalty, the healthcare organization must provide a sense of organizational stability and vie

Chapter 15

Health Professional Leadership

Normal is getting narrower and narrower.

—Personal observation by an experienced nurse practitioner

Health professionals can be important participants in health policy processes. They bring their experiences, their knowledge of both science and art, their ability to distinguish between the two, and their commitment to the patient. Typically, they also bring a commitment to lifelong learning. The power of the professions, especially physicians, has been waning of late, but that has a lot to do with the height of their dominance in the past. In an open, market-driven, information-rich society, the old monopoly power described by Starr (1982) is not sustainable. Health professionals now need to undertake new leadership roles or else their status will be further undermined by those actively seeking a greater share of the pie. Those new roles will have to focus more on collaboration and coordination of care.

15.1 DISINTERESTEDNESS

Much of the diminished respect for health professionals stems from the public’s perception of reduced disinterestedness. Current fashion in economics seems to deny the concept of disinterestedness—the concept of lack of bias and freedom from special interests, the ability to set aside one’s own interests and to seek the best possible outcome for others. The opposite is the oft-repeated phrase, “All they care about is money.” Money is harder to come by in most parts of the health care system because of utilization controls and deep discounts to health care plans, and thus the increased concern is understandable; however, that is not reassuring to the public. Much of the literature on the rising costs of care blames the current fee-for-service system for making it in the providers’ interest to promote overutilization. Schlesinger (2002) argued that this loss of faith seemed to intensify with the advent of Medicare and Medicaid, and that that has led to a loss of political power as well. One parameter of successful professional leadership will be the ability to engender faith that the professional and the profession have the interests of other constituencies in mind.

15.2 INFORMATIONAL CREDIBILITY

Disintermediation in general and direct-to-consumer advertising in particular have affected the informational monopoly of the health professions. This is not a one-way street. The claims and counterclaims of the various interested parties can be hard to sort out. One leadership role for the health professional is to guide the general public through that welter of information. This is not just a physician’s task. It involves all health professionals. An article in BusinessWeek asked, “How Good Is Your Online Nurse?” and compared the online patient portals of the three largest health insurers: WellPoint, United Health Group, and Aetna (Weintraub, 2006). The trends reported in the article included greater integration with patient records, more add-on purchased counseling, and more personalized responses. It concluded, “A bit like Big Brother? Sure. But as health care gets more complex, it’s comforting to have a virtual coach” (p. 89). Despite the word “nurse” in the title, the article compared the companies’ automated systems that tailored the information. One insurer did offer written and telephone nutritional consultations for a fee, but the professional component was largely invisible in the process. Maintaining the power of the professions in the future will require efforts to maintain acceptance as a unique and relevant information domain. There is relatively little art in computerized communications, and the public might well want more in the way of art, if it is offered. Procedural control alone is a slender reed upon which to stake the future of a profession. Conceding the informational domain to others is risky. The countertrend is the rise of boutique medical services, which offer more access and attention for an annual fee.

15.3 TO INFLUENCE GLOBALLY, START LOCALLY

The health professional’s power to participate effectively in the political process is earned through leadership in one’s profession, in one’s institution, and in one’s community. Although some leaders and spokespersons appear to have burst onto the national scene directly—Dr. Donald Berwick in government and health quality improvement, for example; Dr. Atul Gawande with his New Yorker articles and his books; and Dr. Paul Farmer in international health—most rise slowly through the ranks of their profession as team players. The routes to leadership positions are varied. Health professionals are in leadership roles in medical centers, community hospitals, government agencies, and insurance companies. Each presumably came by his or her position by training, intelligence, hard work, and usually trustworthiness. They were able to convince others to work beside them and for them because they could be trusted to take the interests of others into account.

Leadership career paths often overlooked in the health policy arena include those in corporations and in entrepreneurial ventures. A number of very influential health professionals have stopped delivering care directly and have moved into the management of health institutions, insurance companies, occupational health, medical device and supply companies, pharmaceutical companies, and government agencies. They represent those institutions, and many seem able to do so without negating the trust of health care decision makers. Their leadership roles may have been thrust upon them, or they may have sought them. In either case, they took a prepared mind and a sense of what they wanted to accomplish in an arena of health care policy.

The press seems to emphasize the importance of careers in publicly held companies, as considerable wealth can be created by developing a company and taking it public. After the company goes public, however, it is beholden primarily, if not solely, to one set of stakeholders, the stockholders; therefore, there is still a major role in health care for the nonprofit organization that does not have stockholders and can balance a number of competing interests. A deeper knowledge of nonprofit organizations and their behaviors is necessary for determining their role in setting and implementing health policy. This is especially true of entrepreneurial nonprofit organizations that can participate in the marketplace as fully as a stock corporation. Leaders must understand the similarities and differences in how these types of organizations function. The term governance is often applied to the roles of management, staff, and boards of both for-profit and nonprofit organizations. The professional leader must be able to function effectively and help govern effectively in one or the other or both.

15.4 PROCESS INNOVATION

There seems to be a consensus developing that there is great potential in the area of process innovation. This goes well beyond improving current processes and moves into major changes that meet the criteria outlined by the Institute of Medicine’s (IOM) Learning Health System initiative and its Innovation Collaborative (IOM, 2012a, 2012b). Those criteria included:

• A participatory, team-based transparent culture

• Patient-anchored and patient-tested processes

• Fully active and engaged patients and the public

• Informed, facilitated, shared, and coordinated decisions

• Care that starts with best practice every time

• Transparent and constantly assessed outcomes

• Incentives aligned for value

• Knowledge that is an ongoing, seamless product of services and research

• Health information that is a reliable, secure, and reusable resource for the patient and the common good

• Leadership that is multifocal, networked, and dynamic

There is plenty there to work on locally and nationally.

15.5 RISK TAKING

Moving out of a traditional professional role requires dealing with new classes of risks and accepting success as well as failure. There are many successful health professional entrepreneurs and leaders and also some unsuccessful ones. Recent events have shown us situations where successful professional leadership has been followed by failure. An example is the rise of large physician practice management organizations that grew very rapidly in the 1990s but failed as their leaders strayed from their areas of expertise and listened, not to their customers, but to those who were concerned only with increasing stock prices. Chin et al. (2013) point out that the innovators have to accept failure as a natural learning experience and keep trying until things work. That is very different from practicing defensive medicine.

15.6 HEALTH POLICY ANALYSIS: A RELEVANT SCHOOL FOR LEADERSHIP

Participating in policy discussions and analyses can also help prepare one for leadership. By reviewing and critiquing the alterative scenarios provided by scholars—such as the consumer-oriented free-market approach of Herzlinger (1997) versus the community-based planning approach of Shortell and colleagues (1996) versus new approaches being undertaken by the various states—one can learn a great deal. These debates offer a number of intellectual leadership roles for trained policy analysts with professional backgrounds and skills.

Evaluating the alternatives calls for an understanding of the types of risks that health care organizations and health care managers may choose to handle or not handle in the design of their system. These risks have been described as follows (McLaughlin, 1997; McLaughlin & Kaluzny, 1997):

• Underwriting

• Marketing

• Clinical operations

• Financial

• Regulatory

• Integrative

The would-be professional leader has to think through the following questions:

• Which of these risks am I now comfortable handling?

• Which other ones do I need and want to learn to handle?

• How can I use my work or educational experiences to learn to handle those that I want to or will need to handle?

This exercise can help the potential professional leader outline what he or she needs to learn about managerial skills and activities. One must learn to analyze the various organization forms used for health care delivery in terms of how to allocate these risks and facilitate their handling.

15.7 GOVERNANCE

Not only do health care professional leaders make decisions, they also provide what Karl Weick (1995) called “sensemaking” for those being led. They must be able to understand and articulate the role of the governance process in their operation. Health care professionals guard and maintain the technological core of their organizations. They demand a role in their governance processes and governance mechanisms, which are the keys to effective technical and organizational change. Their leaders must understand how these processes operate and how their professions and the other actors can best work together in the policy-making process. Through understanding the risks to be encountered, analyzing the nature of local markets and delivery organizations, and meeting the governance needs of organizations delivering care, health profession leaders can become equipped to analyze local health care systems and how they are best led.

15.8 PLANNING ALTERNATIVES

Professional leaders must analyze policy issues for specific communities and specific segments of health care. These have to be analyzed against specific criteria of quality, access, and cost. One can also master less familiar risks, such as pricing. Leaders must consider quality measurement and improvement and disease-management approaches. Imbedded in such studies are opportunities to develop insights about the ability or inability of organizations to handle high levels of inherent variability in definitions, patients, events, costs, and so on. This needs to be a continuing theme in analysis, one relating back to the issues of art versus science and Deming’s (1986) notions about special cause variation and common cause variation. Health care professions have historically treated all situations, whether art or science, as if they were science. Consequently, they have assumed that any negative consequences were the result of special cause variation, holding the individual practitioner responsible for adverse events. What future managers have to learn from the Deming approach is that health care is a field that will have high variability, even without special cause variation, and that administrative systems have to be tailored to that reality. Success in health care is as much dependent on a team’s functioning in an effective system as it is on any individual professional. Deming, a pioneer in continuous quality improvement, noted (1986) that most quality problems were not due to worker errors, but to problems in the design of the production system that failed to handle inherent variability effectively. Professional leaders must come to understand that assessing and adapting to this inherent variability is a key element of the manager’s role in health care delivery.

15.9 COMMUNITIES

If professionals are to manage populations rather than just individuals, they must develop a sense of how that can be done in a community setting. They must experience and participate in change processes undertaken by groups involving payers, providers, public health agencies, and patient organizations in their own community. They need to understand the limits of community-based cooperation and planning in a market-driven health care system. Leaders must develop sufficient respect among their colleagues to be trusted with data needed for community health improvement when it might otherwise be seen as proprietary information for competitive use.

15.10 ENHANCING THE PROFESSIONAL’S ROLE

Professional performance in health policy roles can be enhanced in a number of ways, including the following:

• Preparation

• Skills development

• Training others

• Educating the public

• Networking

• Practicing leadership

Preparing to Learn and to Lead

Professionals need opportunities to adapt to policy analysis roles above and beyond those normally associated with clinical care. Potential leaders have to walk in the shoes of those who are leading, consider the multiple sides of the issues, use hard facts and fit them into conceptual and mathematical models that allow one to reduce and refine the array of available alternatives, and then select those that are likely to succeed in the field. Health policy analysis invites the potential leader to step back from narrow professional roles, think in terms of what is best for the patient and for society, and see the changes in health care more in the sweep of time. Intellectual integrity also is needed as a bulwark against being swept along with the fads.

One very important role for the health care professional is as a team member. Policy analysis teams require a wide range of skills, including management, economics, operations, and medicine. As the owners of the technological core of medicine, health care professionals can always claim a place at the table; however, they must also be prepared to contribute to the overall progress of process analysis and improvement efforts.

Developing Skills

The policy analyst must also understand the financial implications of what is being discussed; think in terms of markets and competition; adjust to social, economic, and political change as they play out in U.S. society; analyze and optimize processes; and motivate individuals and teams. All of these move in the direction of exhibiting the competence, demonstrating the mastery, and gaining the respect of one’s peers and colleagues expected of a potential contributor to a senior management team. Another skill of senior leadership is that of sensemaking; that is, being able to interpret publicly what is going on in a way that supports positive outcomes. One practice arena would be in explaining the changes in the health care landscape, such as the implementation of the remaining provisions of the Affordable Care Act (ACA), to one’s peers, patients, and the public.

Learning and Training Others

One function of professional leadership is training the next generation of professionals. For example, if health policy is going to focus on motivating the system to reduce waste, as suggested by Porter and Teisberg (2006), then the present and the next generation are going to have to think in terms of value-based patient care and focus on managing the entire medical condition from start to finish. Paul Batalden and others at Dartmouth have already started to incorporate this into their training of physicians there and elsewhere. They refer to it as employing microsystems strategies as compared with organization-centered or issue-centered strategies for process improvement (Mohr & Batalden, 2006). They suggest that there are eight dimensions of effective microsystems (Mohr, Batalden, & Barach, 2006, p. 408):

1. Constancy of purpose

2. Investment in improvement

3. Alignment of role and training for efficiency and staff satisfaction

4. Interdependence of the care team to meet patient needs

5. Integration of information and technology into workflows

6. Ongoing measurement of outcomes

7. Supportiveness of the larger organization

8. Connection to the community to enhance care delivery and extend influence

These eight dimensions align very well with the concepts of the value-based competition model offered by Porter and Teisberg (2006). Adopting that approach in both clinical process improvement and in clinical training is one way to walk the talk, to learn the full implications of such an approach, and to develop the skills and insights applicable at higher levels of policy analysis. If one does not normally use something, one of the best ways to come to understand it fully is to try to teach it to others.

Building Networks

An intriguing part of health policy analysis is that it takes place in a virtual network of participants, professions, and organizations. One learns how influence is exerted nationally, locally, and in one’s work group by knowing when to speak up and when to hold back, when to be the advocate and when to be the analyst, and how to support and move forward the multi-disciplinary team—the key element of health care leadership for many years to come. By doing so, one develops skill at working with other disciplines and the contacts that become important assets as one attempts to exert leadership at higher and higher levels in the policy analysis process.

Practicing Leadership

Potential professional leaders have many opportunities to experiment with leadership roles in their interactions with program peers inside and outside their usual work setting. They can try out new concepts and compare experiences with their colleagues. Buttressed by the knowledge and skills gained, they can gradually assume leadership based on competency and commitment to personal and institutional change. One need not wait for a senior management opening to put that new knowledge to use.

15.11 CONCLUSION

Professionals play a very important role in policy analysis; however, they need to acquire those skills necessary to achieve positions of leadership in health policy making. Professionals, especially physicians, must learn to take a disinterested view in many of their interactions with others, offsetting the growing public perception that they are much too concerned with the monetary aspects of care. If they fail to do so, their professional and political influence will continue to wane as their informational and procedural monopolies weaken.

To start, professionals must begin to influence health policy locally. They have to gain experience and leadership skills at that level before moving up to higher levels. As they move up, they will learn about the governance processes of both for-profit and nonprofit organizations and the suitability of each for specific purposes. They will gain knowledge about managing nonclinical types of risks in the health care setting and about how to become a member of a team that can deal with the entire medical condition rather than their subspecialty’s aspect of it.

Learning by doing is available in all settings, especially in training newer health professionals, improving local care processes, and health policy leadership at the community level. There is plenty of room for professional leaders in the health policy process, if they are willing to invest time and effort into learning to manage and lead in it.

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Case 15: Australian Surgery Indicator Ma…

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Case 15 Australian Surgery Indicator Makes the Front Page

The front page of the Sydney Morning Herald of February 28, 2011, carried an exclusive headlined, “Thousands Hit as Hospitals Cancel Surgery” (Wallace, 2011). It cited public records from NSW Health, the ministry responsible for monitoring New South Wales’ state health system. The records indicated that same-day surgery cancellations were “occurring regularly at three times the accepted standard.” Many patients showed up at public hospitals operated by area health services expecting to go into the operating room, only to be sent home after fasting and having blood samples sent to the lab. In many instances, surgeries were canceled because the hospitals did not have beds waiting for the patients after their surgeries.

The article noted that the ministry’s “Surgery Dashboard,” a monthly snapshot of key performance indicators, sets a target of less than 2% for surgery cancellations. This is a stretch or “aspirational” goal, and some NSW hospitals were not meeting the previous standard of less than 5%.

The Surgical Service Taskforce developed the dashboard, and NSW Health incorporated it into its Pre-Procedure Preparation Toolkit, a guideline issued by the ministry’s Health Service Performance Improvement Branch. Table 15-1 lists the key performance indicators for both state and local levels.

The guideline indicators and targets were reviewed in November 2012, and the canceled surgeries target remained unchanged.

The reporter interviewed the chair of the local Australian Medical Association hospital practice committee, who was also a medical school faculty member. He suggested that the problem was worse than indicated, because patients who wanted surgery but were never booked were not counted. He observed that the benchmark percentage was “ambitious but clearly double or triple that figure is unacceptable.” He called a ministry plan to add 400 public hospital beds per year insufficient.

The deputy director-general of NSW Health told the reporter that 40–45% of the cancellations were for “patient reasons,” such as the patient not showing up or being ill on the day of surgery. He also noted that there were multiple reasons why hospitals could not accommodate surgery patients—when trauma patients unexpectedly tied up ICU beds, for example, or when necessary supplies and equipment were not available. He noted that when the benchmark had been less than 5% nearly all the hospitals had met it, so it was raised to an “aspirational” level of less than 2% in 2007.

Data extracted from the monthly reports by the newspaper indicated that some hospitals were usually failing to meet the less than 5% target and few had come close to the less than 2% level on a consistent basis. The same-day cancellation rate for six of the nine local hospitals was around 4%. This suggests that almost 9,000 same-day surgeries are canceled in New South Wales each year. The deputy observed that a cancellation rate of 4–5% was typical of other Australian states and that 91% of elective surgeries were “completed on time.”

Table 15-1 Key Surgical Performance Indicators

State Level

Booked patient cancellations on the day of surgery for any reason

< 2.0%

Patients canceled due to medical conditions (included above)

< 1.0%

Suggested for Local Level

Patients through the preprocedure preparation process

100%

Percentage of patients processed by:

Target locally determined

Telephone interview

General preadmission clinic

Multidisciplinary preadmission clinic

Average time spent by patient in preadmission clinic

General (anesthetist and nurse)

2 hours

Multidisciplinary

4 hours

Other

Patients who “do not attend” on the day of surgery

< 0.5%

Source: Data from: NSW Department of Health, Guideline: Pre-Procedure Preparation Toolkit, Document GL-2007_018, 02-Nov-2007, p. 18. Accessed December 9, 2013, at www.health.nsw.gov.au/policies/gl/2007/pdf/GL2007_018.pdf

Discussion Questions

1. Do the conclusions you draw from the case justify the headline? Why or why not?

2. Evaluate the indicators shown in Table 15-1. These are not the only indicators. Others included the waiting times for elective surgery by urgency category.

3. What do you estimate is the avoidable rate of canceled surgeries, and how would you develop an indicator for that?

4. How would you factor in the biases of both the doctors and NSW Health?

5. How might you manage the phenomenon that raising the benchmarks to “aspirational” levels means reporting more failures to the public?

6. Investigate the overlapping of private and public hospital systems in Australia. How does this complicate the issues of performance evaluation and improvement? In New South Wales, the Department of Health regulates private facilities and also manages the public ones. What are the strengths and weaknesses of such an arrangement

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Chapter 14

Double-Checking for Contextual Change

Even when a specific policy had been thoroughly analyzed, it still has to be checked against a scenario about what is likely to happen to the system as a whole. Alternative visions, which we call scenarios, need to be considered. For example, a concern about moves that take us closer to universal coverage—whether that means the Affordable Care Act (ACA) as it is more fully implemented or future efforts (such as, potentially, a single-payer system)—is that we could be worse off unless there are concurrent system changes that reduce waste, expand primary care services, and address the impact on prices of treatment access for additional millions of low- and middle-income people. Various provisions of the ACA attempt to address each of these areas, but critics often say it does not do enough to control costs.

A comparison of two offsetting effects of an alternative decision is a trade-off analysis. That is one step in comparing outcomes, but it is still a very narrow picture in terms of the transparency of unintended consequences and secondary and tertiary effects. Trade-offs should be considered throughout the analysis. After the trade-offs have been evaluated and the alternatives narrowed down, the relevant scenarios will become apparent.

In the field of health policy, consensus is hard to come by, and even harder to sustain. There are certain conclusions, however, that seem to be inescapable:

• Without major interventions, health care will be near or at 20% of GDP over the next decade. No government is likely to risk too radical a change in that large a portion of the economy, especially while contending with other issues, such as international competition, immigration, terrorism, and government deficits.

• The moves of employers away from responsibility for paying health insurance premiums for workers, workers’ families, and pensioners will continue despite the mandates in the ACA. The availability of an alternative path to coverage for employees of small businesses—namely the exchanges—is likely to accelerate this trend. Some larger employers may also chose to pay the penalty rather than provide “shared responsibility” coverage for all full-time employees.

• Insurance companies will come up with less expensive products for individuals (with lesser coverage) to adapt to the changing market. The risk has always been that these basic packages and new exclusions create another class of underinsured individuals and possibly drive up the premiums for the chronically ill and others who require more comprehensive coverage. This process will be shaped by the “minimum value” and “minimal essential coverage” provisions of the ACA.

• The unique aspects of health care in terms of uncertainty, agency conflict, and market failure will constrain the degree to which free-market solutions will take hold.

• Consolidation will increase the possibilities for better coordination of care but risk further increase in the market power of providers.

• Communicable disease events in other countries will affect the United States much more rapidly because of global transfers of people, foodstuffs, money, and information.

• The flow of physicians into the United States for training and their subsequent experiences practicing here will set up the potential for a competent workforce elsewhere, as we now see returnees performing hip and heart valve replacements in a number of countries at a third of the cost, with international middlemen brokering such services.

• Similarly, but more darkly, the illicit market in transplantable organs is growing rapidly, again through middlemen. There is also the international trade in prescription drugs, which is primarily attributed to Canada but is really wider and has great growth potential. Unfortunately, it opens up an entryway for counterfeit drugs as well.

• The perceived future insolvency of the Medicare “insurance” system will put pressure on the federal government, but that reckoning will likely be postponed because it will be beyond the reelection time horizons of most politicians. States will continue to deal with the burden of the working poor under the ACA and Medicaid. Even states not participating in Medicaid expansion are expected to see increased enrollment and a rise in associated costs as a result of the ACA, and those participating in t

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