There is a new overarching strategic imperative in health care: developing and embedding a culture of value throughout the enterprise. It is about articulating a vision across the continuum of care saying, “We will be the value leader in the markets we serve because we are recognized as providing the greatest value.”
It is about delivering the total package of the value equation, consisting of clinical quality, service quality and access, divided by cost. For a hospital or health system to attain a value-leader position will require top-quartile performance in order to be included in the emerging risk-sharing models being developed by the major health care payers. Driving the change is the Centers for Medicare & Medicaid Services, which has a stated goal of driving 80 percent to 90 percent of Medicare patients to value-based models focused on clinical quality, coordinated care and premium cost effectiveness by 2018.
Who is included in ‘we’?
When we say, “We will excel at delivering on the value promise,” who are we talking about? Does “we” include the shared-risk partners needed for success, such as rehab, home health, skilled nursing facilities, behavioral health, pharmacy and so forth? Certainly, a clear understanding of what our vision entails must include thousands of front-line caregivers — and most critical to our success, physicians. When asked if this vision statement includes them, most employed physicians say yes. But the majority of the medical staff at large, i.e., those not employed by the hospital or system, will quite often state that they are not involved: “That is the hospital’s thing.”
If all of these caregivers need to be included in the “we,” do they know it? Are they represented in planning initiatives? Is there real-time communication and coordination across the continuum of care? Are they involved in establishing and monitoring the metrics on which they will be judged?
Mutuality of interests
About 100 years ago, American sociologist and theorist Mary Parker Follett wrote two management classics, The New State and Creative Experience. She developed the concept of the “mutuality of interests,” which holds, “When you have made your employees feel that they are in some sense ‘partners’ in the business, they do not improve the quality of their work, save waste in time and material, because of the Golden Rule, but because their interests are the same as yours.”
When our continuum partners and our physicians and community service entities are made to feel that they are indeed partners in a significant effort to deliver value to the community, their interests will be the same as ours. When the culture inside the organization, at the day-to-day delivery level, is one in which all of the employees understand the vision and know where they add value, goals will be achieved. The culture of “we” is one in which employees are eager to participate in driving value and have no trouble coaching others in “the way we do things here.”
It is totally unrealistic to think that a hospital or health care system can be successful in the world of value-based payment without a true partnership with its physicians. They are the critical component of “we.” And yet, in too many hospitals, the struggle is the same as it has been for decades. Alignment and engagement remain elusive, and there is no simple solution.
In a fall 2015 survey of more than 350 physicians, health care consultancy the Studer Group found that 90 percent have experienced some form of burnout. Contributing most to burnout were loss of control, downward pressure on compensation, a sense of disconnection from patients and the community, and paperwork and regulations in the health care environment itself. Interestingly, when asked if they would like a new role, the physicians responded they would prefer to have a larger impact on the changes that are occurring and a greater sense of say in operational decisions.
They are overburdened and stressed, but their desired role is to have more input and a greater voice. This raises a number of questions for a hospital or health system: Who are the physician leaders who desire to have an impact, and how do we provide them a platform to have meaningful input? Have we articulated a clear and compelling vision that spells out the roles that physicians will play in our future success? Are physicians occupying seats at the meetings where key decisions are being made? Are the seats in the C-suite still mostly filled with administrative folks, or are physician leaders playing a meaningful role?
New models, new structures
In the early 1990s, the senior leadership team at Sentara Health in Norfolk, Va., consisted of the CEO, an executive vice president and eight corporate vice presidents. Faced with significant cost pressures, new managed care initiatives in the marketplace and the need to build greater trust with physicians, Sentara created a group of four executives and four physicians to serve as the advisory council to the CEO. As a member of this council, I witnessed a dramatic change in the agenda.
Every Monday, for the next several years, this transitional council met to address the issues facing the system. In addition to budgets, growth and strategic planning, we now also focused on clinical quality, patient satisfaction and issues that mattered to patients and the physicians. The merging of physician interests with those of the system enabled the development of a provider-sponsored HMO in a 50/50 partnership with an independent physician association of 250 of our physicians.
This governance structure created an alignment that had not been present before the transitional council was formed. The structure also created an environment in which the physician perspective on value helped place the patient in the center of the delivery model, changing the focus from provider-centric solutions to patient-centric ones.
Value creation is the axis around which health care delivery will revolve, and all care partners must have a shared interest in the same vision, value proposition and measures of success. Creating a structure, like the executive council, in which physicians and continuum partners have an impact on the changes that are occurring — and a greater sense of say in operational decisions that create value — will go a long way to creating a culture of “we.”
Jack McNamara is an independent health care consultant based in Virginia Beach and a former senior vice president of Sentara Health.